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COPYRIGHT DEPOStT. 




DISEASES 

OF THE 

DIGESTIVE ORGANS 

IN 

INFANCY AND CHILDHOOD. 



STARR. 



BY DR. LOUIS STARR. 



THE HYGIENE OF THE NURSERY. 

INCLUDING THE GENERAL REGIMEN AND FEEDING OF 
INFANTS AND CHILDREN AND THE DOMESTIC 
MANAGEMENT OF THE ORDINARY EMER- 
GENCIES OF EARLY LIFE. 

Sixth Edition. Enlarged and Improved. 

WITH TWENTY-FIVE ILLUSTRATIONS. 
J2mo. 293 Pages. Cloth, $1.00. 



Designed for the use of Parents, Nurses, and all 
interested in the Care and Management of Children. 

*** This book contains very complete directions for the proper 
feeding- of infants : ist, From the maternal breast. 2d, By wet- 
nurse, including rules for choosing the woman. 3d, Artificial 
Feeding. This part of the subject is elaborated carefully, so 
as to include everything of importance, and will be found of 
great service to the monthly nurse. General and specific rules 
for feeding are given, and Diet Lists from the first week up to 
the eighteenth month, with various recipes for artificial foods, 
peptonized milk, etc. Directions for the Pasteurization and 
sterilization of milk, substitutes for milk, preparation of food 
for both well and sick children, nutritious enemata, etc., and the 
general management of the Nursery. 

P. Blakiston's Son & Co*, Philadelphia. 



DISEASES 



DIGESTIVE ORGANS 



INFANCY AND CHILDHOOD 



CHAPTERS ON THE DIET AND GENERAL MANAGEMENT OF 
CHILDREN, AND MASSAGE IN PEDIATRICS. 



LOUIS STARR, M. D., 



LATE CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN THE HOSPITAL OF THE 

UNIVERSITY OF PENNSYLVANIA; CONS''ITINC PEDIATRIC TO THE 

MATERNITY HOSPITAL, , PHI J- AI>ELFF,i A, ETC. - 







1IR 


D EDIT ION— REWRITTEN AND ENIARGE 




ffllustratefc 




PHILADELPHIA : 


P. 


*BLAKISTON'S SON & CO., 




No, 1012 Walnut Street. 




1901. 



,bA 






THE LIBRARY OF 
CONGRESS, 

Two Copies Received 

SEP. 11 1901 

Copyright entry 
LASS Os XXc. N«. 
COPY B. 



Copyright, 1901, by Louis Starr, m.d. 



PRESS OF WM. F. FELL & CO, 

1220-24 Sansom Street, 

philadelphia. 



PREFACE TO THE THIRD EDITION. 



During the ten years that have elapsed since the publica- 
tion of the last edition of "The Diseases of the Digestive 
Organs in Infancy and Childhood," the whole subject of Pedi- 
atrics has been so greatly advanced, and our knowledge of the 
dietetics of both well and ill children and of therapeutic pro- 
cedures has grown so much more extended and accurate, that 
a revision of the original work has become necessary to its 
continued usefulness. This revision the author has endeavored 
to make as thorough as possible, at the same time adding a 
number of new chapters and omitting much obsolete matter. 

Of the additions the most important are the sections on 
Simple Atrophy, Infantile Scurvy, Rickets, Lithaemia, Infec- 
tious Follicular Tonsillitis, Naso-pharyngeal Adenoid Hyper- 
trophy, Proctitis, and Appendicitis. Extensive changes also 
have been made in the section on Feeding. 

Since, for the successful management of diseases of the di- 
gestive organs in the young, so much depends upon careful 
choice of food and sound hygienic measures, greater stress has 
been laid, in this as in the former editions, upon dietetics and 
general regimen than upon the mere administration of drugs, 
though the question of appropriate therapeutics has not been 
neglected. 

The author is indebted to Dr. Thompson S. Westcott for 
efficient and interested aid in guiding these pages through the 
press and in preparing the index. 

LOUIS STARR. 

1818 Rittenhouse Square, S., Philadelphia. 
September 1, igoi. 



CONTENTS. 



INTRODUCTION. 

The General Management of Children. 

PAGE 

i. Feeding, , 18 

2. Bathing, 77 

3. Clothing, « 80 

4. Sleep, 81 

5. Exercise, 83 

6. Management of Weak and Immature Infants, 84 

Massage in Pediatrics, 92 



PART I. 

Diseases Produced by Improper Food and Imperfect Nutrition. 

CHAPTER I. 
Simple Atrophy, 101 

CHAPTER II. 
Scorbutus, m 

CHAPTER III. 
Rachitis, , 130 

CHAPTER IV. 

LlTH^MIA, 159 

PART II. 

Diseases of the Digestive Organs. 

CHAPTER I. 

Affections of the Mouth, 175 

Catarrhal Stomatitis, 175 

Aphthous Stomatitis, 178 

vii 



Vlll CONTENTS. 

PAGE 

Bednar's Aphtha, 183 

Ulcerative Stomatitis, e , 183 

Gangrenous Stomatitis — Noma, 189 

Parasitic Stomatitis — Thrush, 195 

Membranous Stomatitis, .' 202 

Syphilitic Stomatitis, , , 203 

Dentition, 205 

CHAPTER II. 

Affections of the Throat, 211 

Simple Pharyngitis, 211 

Superficial Catarrh of the Tonsils, 215 

Acute Follicular Tonsillitis, 215 

Peritonsillar Abscess or Suppurative Tonsillitis, 221 

Hypertrophy of the Tonsils, 227 

Naso-pharyngeal Adenoid Hypertrophy, 230 

Retropharyngeal Abscess, 233 



CHAPTER III. 

Affections of the Stomach and Intestines, 237 

Acute Gastric Catarrh, 237 

Chronic Gastric Catarrh, 240 

Ulcer of the Stomach and Haematemesis, 249 

Softening of the Stomach (Gastro-Malacia), 252 

Chronic Gastro-Intestinal Catarrh, 252 

Acute Intestinal Catarrh (Simple Diarrhoea), 268 

Chronic Intestinal Catarrh — Chronic Entero-Colitis, 276 

Entero-Colitis, * 289 

Cholera Infantum (Acute Milk Infection), 302 

Inflammation of the Colon and Rectum — Ileo-Colitis — Dysentery, . . 309 

Proctitis, 3 J 7 

Colic, 320 

Habitual Constipation, ... . . 323 

Appendicitis, 331 

Intussusception, 340 

Intestinal Worms, 356 

CHAPTER IV. 

Tuberculosis of the Mesenteric Glands and Intestines, .... 376 

Tuberculosis of the Mesenteric Glands, 376 

Tuberculosis of the Intestines, 383 



CONTENTS. IX 

CHAPTER V. PAGK 

Affections of the Liver, 387 

Jaundice, 387 

Congestion of the Liver, 393 

Fatty Liver, 396 

Amyloid Liver, 398 

Syphilitic Inflammation of the Liver, 401 

Cirrhosis of the Liver, 403 

Suppurative Hepatitis, 408 

CHAPTER VI. 

Affections of the Peritoneum, 413 

Peritonitis, 413 

Tuberculous Peritonitis, 421 

Ascites, 428 

Index, 435 



DISEASES 



THE DIGESTIVE ORGANS 



INFANCY AND CHILDHOOD. 



INTRODUCTION. 

I. The General Management of 
Children. 



It is the duty of the child's physician not only to remove 
disease, but also to manage convalescence and everyday life 
in such a way that the little subjects confided to his care may 
be led to complete recovery, and kept in as perfect health as 
possible. To accomplish these objects in any abnormal con- 
dition, but particularly in the special class of maladies to be 
presently considered, the ability to direct intelligently the daily 
regimen is much more important than a mere knowledge of 
drugs and of the principles of therapeutics. 

The daily regimen embraces several factors : these are feed- 
ing, bathing, clothing, sleep, and exercise, and under such 
headings the subject will be briefly outlined, for little more is 
possible, in the present chapter. 
2 17 



1 8 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

i. Feeding. 

Age bears so close a relation to the choice of food and the 
method of feeding, that it will greatly simplify the study of 
these questions to consider them from the standpoint of the 
two stages of a child's life, namely, infancy, or the period ex- 
tending from birth to the age of two and a half years ; and 
childhood, the time elapsing between completion of the first 
dentition and puberty. 

An infant may be fed in either one of three ways — first, 
from the mother's breast ; second, from the breast of a wet- 
nurse ; and third, from a bottle, the latter being the method 
known as artificial or hand feeding. 

First. Feeding from the Maternal Breast. — There can be 
no doubt that this, being the natural, is at the same time the 
proper method of nourishing the human infant ; and fortunate 
is the babe that in our day of advanced civilization and city- 
living can draw from the breast of a robust mother an abun- 
dant supply of pure, health-giving, tissue-building food. 

It follows, therefore, that every woman who is free from 
certain contraindicating diseases, to be mentioned later, should 
nourish her child solely from her breast up to the age of eight 
months, and partially to the end of the first year, or, failing in 
either limit, so long as possible. 

The infant should be put to the breast as soon as the mother 
has recovered somewhat from the fatigue of labor — some four 
or eight hours after birth. Of course, no milk can be drawn 
at this early stage, but the babe gets a small quantity of thin, 
watery fluid, called colostrum, which affords sufficient nourish- 
ment and at the same time, from its laxative properties, clears 
away the greenish or black, viscid material that collects in the 
infant's intestinal canal during intra-uterine life. This pro- 
cedure, too, is of great advantage to the mother, for it insures 
proper contraction of the womb, draws out the nipples, and 
encourages the formation of milk. 



THE GENERAL MANAGEMENT OF CHILDREN. 1 9 

As the secretion of milk is never fully established until the 
third day after labor, it stands to reason that no food other than 
the colostrum is required before that time. Hence the prac- 
tice of filling the infant's stomach with gruel, sugar and water, 
and other sweetened mixtures, is more than useless, for it 
diminishes the activity of sucking and the consequent stimu- 
lation of milk production. Put the child to the breast every 
two hours while the mother is awake, and there need be no 
fear of starvation. 

After the third day, should the breasts not yield a supply 
of milk, a mixture of two fluidrachms of cream, three flui- 
drachms each of whey and water, and twenty grains of sugar 
of milk may be given every fourth hour, the babe being put 
to the breast in the meanwhile. So soon as the flow begins, 
however, the artificial feeding is to be discontinued. 

Usually on the fourth day milk is secreted and regular lac- 
tation commences. Many untrained mothers make a failure 
of nursing because they know nothing of the manner of giving 
suck ; of the length of time the child should be kept at the 
breast ; of the proper time for, and interval between, feeding ; 
and of the importance of regularity. Upon these points the 
physician should give minute instructions. 

When taking the breast, the infant must be held partly 
on its side, on the right or left arm, according to the gland 
about to be drawn, while the mother must bend her body 
forward, so that the nipple may fall easily into the child's 
mouth, and steady the breast with the first and second 
finger of the disengaged hand, placed above and below the 
nipple. In case the milk runs too freely — a condition very 
apt to excite vomiting — the flow is easily regulated by gentle 
pressure with the supporting fingers. Each of the breasts 
should be drawn alternately, the contents of one usually 
being sufficient for a meal ; and a healthy child may be 
allowed to nurse until satisfied, when he will stop of his 



20 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

own accord, drop the nipple and fall asleep with milk still 
flowing over his lips. 

During the first six weeks the breast is required every 
second hour, from 5 a. m. until 11 p. m. At night the infant 
should be put in a crib by the mother's bed, or in an adjoining 
room, under the care of a competent nurse, and there remain 
quietly until the morning feeding. This secures the mother 
six hours of uninterrupted repose, a matter of great importance 
to her general health and consequent capacity for prolonged 
lactation. As to the infant, he may rebel at first, and wake 
and cry, so that it is necessary to quiet him with a little milk 
and water administered from a bottle ; but often after a few 
days, and certainly at the end of a week or two, the good habit 
of sleeping at night is formed, and there is no further trouble. 

Regularity in meal hours is even of more importance in 
early than in adult life, on account of the natural feebleness 
of digestion. To secure this, it is only necessary to have a 
little perseverance, for infants are such creatures of habit that 
a short training brings them into the way of expecting food 
only at certain times, and, when healthy, they wake to suck 
the breast with almost the precision of the clock. While in- 
sisting upon this rule, one must recognize the fact that, 
although in the vast majority of instances a two-hours' inter- 
val is most suitable up to the second month, there is no abso- 
lute law as to the number of daily nursings. Some infants 
seem to need food less frequently, and it is best to respect 
their peculiarity and not force the breast upon them so long 
as they sleep well, do not fret when awake, and thrive gener- 
ally. Others, again, may require it oftener ; every hour and 
a half, perhaps, and once or twice at night. In these excep- 
tional cases an appropriate schedule can only be made by close 
observation of individual characteristics. 

A common and most ruinous mistake is to resort to constant 
feeding as a means of pacifying crying. Babies certainly do 



THE GENERAL MANAGEMENT OF CHILDREN. 2 1 

cry from hunger, but just as frequently the crying results from 
colic, or from the discomfort and pain of indigestion. Every 
mother should be able to recognize the difference. The cry 
from hunger usually begins after a sound sleep. It is not 
peevish, and stops at the sight of the breast, when the infant 
rouses himself, presents an expression of pleasure, clinches his 
hands and flexes his limbs. The cry of colic is violent and 
paroxysmal ; the face is livid and wears an expression of suf- 
fering ; the abdomen is distended and hard ; the hands and 
feet are cold ; the legs are drawn up or kicked violently about ; 
and an explosion of wind from the mouth or bowels ends the 
attack. A peevish cry, hot skin, and sour breath attend indi- 
gestion. 

It stands without saying that the cry of hunger must be 
relieved by giving food ; but this is the very worst thing to 
do under other circumstances, for it both breaks up good 
habits and produces serious mischief. The pain of colic and 
the discomfort of indigestion are chiefly due to the accumula- 
tion of flatus resulting from the fermentation of food. Mothers 
soon learn, and unfortunately infants too, that the breast milk 
temporarily relieves suffering. This it does in the same way 
as any other warm liquid ; but, unlike a simple fluid, milk only 
adds more material to the already fermenting contents of the 
gastro-intestinal canal, and every nursing is soon followed by 
more pain, until, between crying and sucking and sucking and 
crying, the infant's life is passed in misery, if not cut short 
altogether. Instead of continuous feeding, the plan for relief 
is to decrease the quantity of food by increasing the intervals 
between nursing and by abridging the time of lying at the 
breast. 

After the sixth week the interval between nursing may be 
slowly increased until, by the sixth month, it reaches three 
hours. During this period, also, the time of lying at the breast 
may be gradually lengthened, for the quantity of milk secreted 



22 DISEASES OF DIGESTIVE ORGANS IN* CHILDREN. 

and the child's appetite and capacity for food are all augmented 
as the days pass by. At the end of the seventh month feed- 
ing every fourth hour suits some children well, but, as a rule, 
the three-hour interval must be adhered to from the sixth 
month to the end of lactation. 

After the sixth or eighth month " mixed feeding " — breast- 
and bottle-feeding alternating — is advisable, if the babe ceases 
to gain strength and flesh while on the breast alone. Other- 
wise, the maxim of not interfering with any course that is 
doing well is as applicable here as elsewhere, and the breast 
may be relied upon entirely until the time comes for weaning. 
Should additional nutriment be required, the food must be 
selected with due reference to age, and prepared in the same 
manner as in regular hand-feeding. 

The date of weaning cannot be fixed for all cases, since it 
must depend upon two conditions — the health of the mother 
and the development of the child. When the former continues 
to be robust and the child steadily grows and gains flesh, lac- 
tation can be prolonged until the tenth or twelfth month. If 
persevered in longer, the mother's strength begins to fail, her 
milk is lessened in quantity or becomes poor in quality, the 
child's nutrition suffers, and he grows pale, thin, and flabby, 
and may become rachitic. 

Weaning may be accomplished gradually or suddenly. In 
gradual weaning about four weeks are required to prepare for 
the absolute withdrawal of the breast. For instance, if suck 
be given every three hours, from 5 A. m. until 11 p. m., or 
seven times a day, there should be, during the first week of 
preparation, one artificial feeding and six nursings daily ; during 
the second, two and five ; during the third, four and three ; 
during 1 the fourth, six and one. Then the breast must be 
entirely withheld. Carefully modified cows' milk, adminis- 
tered from a bottle, is the best substitute. At the age of ten 
months a mixture that ordinarily agrees well is : 



THE GENERAL MANAGEMENT OF CHILDREN. 23 

Cream, f^ ss 

Milk, 15 iv 

Sugar of milk, 3] 

Water, , f^iss. 

This is to be poured into a perfectly clean bottle, warmed 
in a water-bath, and taken through a clean, plain rubber tip. 
Should the quantity (six fluidounces) be insufficient to satisfy 
the child's appetite, the milk and water may be increased until 
the mixture measures seven or even eight fluidounces, accord- 
ing to the demand. 

When such accidents as fever, disordered digestion, with 
vomiting and diarrhoea, or the actual cutting of one or more 
teeth occur during the period of preparation, the number of 
artificial feedings must be reduced, or the breast resumed until 
the disturbance be passed ; then the course may be begun 
again and carried to its completion. 

Usually there is little trouble in weaning infants in this way. 
Sometimes they become fretful under the change and may 
refuse food entirely for a day or more ; but a little determi- 
nation on the part of the mother and the cravings of hunger 
will soon overcome this difficulty. 

Occasionally the child refuses to suck milk from a bottle or 
to drink it from a cup or spoon ; in fact, seems to object to 
any form of liquid food except that drawn from the mother, 
while at the same time he is eager for bread or other solid 
food. Under these circumstances prepare for each meal a 
moderate portion of either rice pudding or junket. After these 
have been taken for a day or two, add to each meal a little 
milk, reducing the amount of pudding or junket, stir the whole 
together, and feed from a spoon ; next day still further reduce 
the solid and increase the liquid, and so proceed until finally 
a taste for milk is cultivated. 

Sudden weaning is more difficult to accomplish, and- is not 
advisable unless, while the breast is being presented, there is 



24 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

an absolute refusal to take artificial food from either a bottle 
or a spoon. This is most apt to occur when food has been 
given too frequently, and when the breast has been used as a 
means to quiet crying. Sudden weaning is also to be recom- 
mended when the mother's health becomes so affected as 
to render any further sucking a positive peril to the child's 
life ; attacks of erysipelas or of smallpox are instances in 
point. 

The physician is often forced to decide upon the advisability 
of premature weaning. His decision must be made cautiously 
and after thorough investigation of two propositions : namely, 
(a) the effect of further lactation upon the health of the 
mother, and (p) the requirements of the child. 

(a) Lactation being a physiological process is not a drain 
upon the systemic strength so long as the functions of nutri- 
tion are actively performed, but under other circumstances it 
very frequently becomes so. Premature weaning is necessary 
when the mother is attacked by any acute disease threatening 
dangerous temporary prostration, such as typhoid or typhus 
fever. A change must also be made if pulmonary consump- 
tion be developed, or, being already present, rapidly advances 
under the drain of milk secretion. Ordinarily, however, the 
general condition that leads to withdrawal of the breast is 
one of simple loss of strength and flesh on the part of the 
mother. 

Undoubtedly these indications often warrant the procedure ; 
but every one who has seen much of children's practice must 
have met with many cases in which the advice to wean has 
been given carelessly and unnecessarily, and in which the 
child might have had its natural food had proper attention 
been given to the health of the mother. If a woman be worn 
out by household cares ; if she wear herself out by a round 
of dinners, balls, or shopping, or if she expose herself to 
injurious atmospheric conditions and eats improper food, she 



THE GENERAL MANAGEMENT OF CHILDREN. 25 

grows weak and thin whether she be nursing or not ; and a 
woman heedless of her health will probably care little whether 
she suckles her child or gives it up to a wet-nurse or to the 
bottle. 

In addition to making nursing the important duty of her 
life for the time being, a mother must be as free from house- 
hold cares as possible. Mental and physical fatigue is to be 
avoided, sufficient exercise must be taken to maintain a 
healthy appetite and digestion, and abundant time devoted to 
rest and sleep. Beyond securing a plentiful supply of plain 
and easily digestible food, with a judicious portion of meat, 
vegetables, and fruit, it is unnecessary to give special attention 
to the diet. 

Should the secretion of milk be scanty, it may often be 
increased by the free use of milk, animal broths, chocolate, 
gruel, and malt extracts. Such tonics as ferrated elixir of 
cinchona, bitter wine of iron, and the preparation known as 
" beef, wine and iron " are useful when there is anaemia, or 
when the general failure of strength cannot be overcome by 
food and attention to hygienic rules. 

The ordinary local conditions indicating the necessity of 
premature weaning, on the mother's account, are fissures of 
the nipple and mammary abscess. 

Fissure being usually an unilateral condition, it is only 
necessary to retire the affected side from duty and to nourish 
the child alternately from the unaffected gland and from the 
bottle until healing takes place, the disabled breast being 
pumped in the mean time to keep up secretory activity. 
Should both sides be affected, weaning may be imperative, on 
account of the extreme pain produced by sucking ; though 
even under these circumstances an effort must be made to 
maintain the flow of milk by regular pumping. Sometimes 
women are able to struggle through the attack by taking 
advantage of the protection afforded by a nipple-shield. 



26 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Fissures of the nipple may be preceded by various diseases 
of the delicate skin of the part. They result, also, from 
want of cleanliness or from keeping the nipple too moist, as 
when constant sucking is allowed or when there is a continual 
flow of milk. They may be prevented by proper attention 
to the nipple before confinement. During the latter months 
of pregnancy the clothing covering the breasts must be loose. 
Each day, for three months before labor, the nipple should 
be washed thoroughly with hot water in the evening and 
anointed with cacao-butter in the morning. At the same 
time, should the nipples be small or retracted, the woman 
must be taught to use her thumb and finger to draw them 
out. This process is not only an advantage in giving proper 
size and shape, but brings the skin into good condition with- 
out hardening it. The application of alcoholic and astringent 
lotions is not to be recommended. They tend to harden the 
tissue, which should be soft and pliable rather than tanned, 
and render the nipples liable to crack. 

When a fissure exists, it is best to see first whether or not 
nursing can be continued by means of a nipple-shield. Should 
the child refuse this, a good plan is to fill the shield with warm 
milk and invert it over the nipple. The infant then draws the 
fluid at once and without difficulty, and will often continue 
sucking until the breast milk follows. After nursing and re- 
moving the shield, the nipple must be dried thoroughly with 
absorbent cotton, and the following lotion applied with a 
camel's-hair brush : 

&. Acid, borici, gr. xx 

Mucilag. acacioe, f^j. M. 

(//) On the part of the infant, there are several indications 
for anticipating the time of withdrawing the mother's breast. 
It must be done if the occurrence of pregnancy or the recur- 
rence of menstruation render the milk unwholesome ; if the 



THE GENERAL MANAGEMENT OF CHILDREN. 2J 

mother contract a dangerous contagious disease, as smallpox, 
scarlet fever, or erysipelas ; if the mammary glands become 
inflamed ; if the breast does not afford sufficient nourishment 
and artificial food be refused ; and, finally, if dentition be 
markedly delayed and the premonitory symptoms of rickets 
appear. 

As to the amount of nourishment, it must be remembered 
that the breast milk may be of good quality, but so diminished 
in quantity that it is insufficient ; or, while abundant in quan- 
tity, so poor in quality that it does not meet the demands of 
nutrition. Even without a minute examination of the milk, 
it is possible to form a good idea of which condition is present 
from the behavior of the infant in the act of sucking. If the 
milk be good in quality but deficient in quantity, the babe, 
when put to the breast, seizes the nipple as if famished, and 
draws upon it vigorously for a time, and then drops it with a 
scream of rage. On the contrary, should there be an abundant 
supply of poor milk, the nipple is grasped languidly, the child 
lies a long time at the breast and falls asleep there. 

Consideration of the final indication opens the question of 
the propriety of regulating weaning by the progress of den- 
tition. This is certainly a good guide, but not in the way im- 
plied in the old precept, that the child must not be taken from 
the breast until evolution of the stomach and eye teeth. In- 
sufficient food is one of the chief causes of rickets, and rickets 
more than any other disease delays dentition ; consequently, 
should the teeth not pierce the gum in time, the inference is 
for other food rather than a continuance of the faulty maternal 
supply. 

Upon deciding to anticipate the time of weaning, the next 
point to consider is whether the infant shall be brought up 
by hand or by a wet-nurse. 

Second. Feeding by a Wet-nurse. — The advantage of feed- 
ing from the breast of a wet-nurse is that the mother's milk 



28 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

is substituted by the milk of another woman ; in other words, 
that natural feeding is continued — a matter of moment in all 
cases, and of inestimable importance with delicate children. 
The disadvantage consists in the difficulty of finding, in a 
woman belonging to the class from which wet-nurses come, 
all the moral and physical characters essential to a good sub- 
stitute, and in the fact that a stranger is introduced into the 
household, often to deceive and annoy the family, and on the 
slightest provocation to leave her charge to fate or to the 
tender mercies of another of her kind. For these reasons it is 
preferable, in the majority of instances, to trust to careful 
bottle-feeding. Nevertheless, as some children must have 
human milk if their lives are to be saved, the rules for select- 
ing a wet-nurse must be understood. 

The woman chosen must be strong and robust, but rather 
spare than fat. Her bill of health must be perfectly free from 
hereditary tendency to mental or physical disease and from 
taint of syphilis or tuberculosis. She must be cheerful, good- 
natured, active, careful, and temperate in habits. Her age 
should be between twenty and thirty years ; she should under- 
stand the care of an infant and the manner of giving suck ; 
her child ought to be nearly the same age as the infant to be 
adopted, and she must be able to afford an abundant supply of 
good milk. 

The last quality can be estimated by inspecting the breasts, 
by examining some of the milk drawn by a pump, and by 
ascertaining; the condition of the woman's own child. The 
breasts of a good nurse are not necessarily large, but are firm 
to the touch and pyriform in shape, with well-developed, 
prominent nipples, and with the skin distinctly marbled with 
large blue veins. The milk, which ought to flow readily on 
pressure or on suction, should be opaque and bluish-white in 
color, have a specific gravity of 1.03 1, an alkaline reaction, 
and show, when placed under the microscope, a number of 



THE GENERAL MANAGEMENT OF CHILDREN. 20, 

minute, equal-sized fat globules. Its quantity may be ascer- 
tained by weighing the child before and after sucking, the 
normal gain being from three to six ounces. There is, how- 
ever, no better or more readily applied test of the quality of 
a nurse than the size, weight, and general development of her 
own child ; and if it be weak and ill-nourished, no amount of 
fitness in other respects can warrant her engagement. 

Even when a woman is found fulfilling in her single person 
all the required conditions — a rare thing, indeed — it does not 
necessarily follow that her milk will suit the babe to be 
suckled. Then changes and new trials must be made until 
the desired end be attained. 

The diet of a wet-nurse and the manner of weaning must be 
governed by the rules already given for maternal guidance. 

Personally, I have had such good results from carefully 
regulated bottle-feeding, that I have almost given up the em- 
ployment of wet-nurses, preferring to regulate the artificial 
food myself rather than allow an ignorant woman to supple- 
ment surreptitiously her deficient supply of breast milk by an 
unskilfully proportioned food — an event of not uncommon 
occurrence. 

Third. Artificial Feeding. — In my experience, there are 
few American women, especially in the well-to-do classes, 
who do not look upon the duty of nursing their babies as a 
pleasant one ; but there are many who are completely unable 
to do so, and a vast number in whom the secretion of milk 
fails after a few weeks or months of lactation. They must, 
therefore, through no fault of their own, resort to a wet-nurse 
or to artificial feeding. Usually, they select the latter method, 
with results that vary in direct proportion to the care and in- 
telligence displayed in carrying it out. 

There is no artificial food equal to the infant's natural food — 
good breast milk. The fluid, however, secreted from the glands 
of a feeble or unhealthy mother, though often sufficient in 



30 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

quantity to fill the suckling's stomach and satisfy the cravings 
of hunger, does not contain enough pabulum to meet the de- 
mands of nutrition. In such unfortunate cases, good cows' 
milk, properly modified, is a better food than the bad breast 
milk. More care and trouble, though, are involved in bottle 
than in breast feeding. If the child has been nourished in 
the natural way — i. e., breast-fed — even for a few weeks, the 
task is far easier to accomplish. In these cases the stomach 
and intestinal canal, inactive in foetal life, are trained to their 
new duties under normal conditions, and so prepared for the 
digestion of properly selected artificial food. So, too, when 
the powers of digestion are inherently active. On the con- 
trary, if the infant must be bottle-fed from the first, or if diges- 
tion be naturally feeble, great difficulty may be expected, and 
most skilful handling is necessary. 

To insure success in hand-feeding, it must be remembered 
that an infant is not nourished simply by the food he swallows, 
but by that portion of it he digests and assimilates. The best 
diet, therefore, is one so adapted to age and digestive power 
that everything eaten will be digested and absorbed. But as 
children differ as much in constitution as in feature, it is im- 
possible to formulate exactly a food that will be applicable to 
every case, or one that needs no change from month to month 
of progressing growth. As age and strength increase, there 
is a corresponding development of the gastro-intestinal 
functions and a demand for more and stronger food. On the 
other hand, should the system be accidentally reduced by 
disease, the digestion, sympathizing in the general debility, 
temporarily loses its normal activity and assumes that of an 
earlier age. In such a case more nourishment is certainly 
needed to build up the failing strength, but it is to be supplied 
by giving such food as can be completely assimilated, and not 
by forcing down strong food merely because it is strong ; for 
the latter, when not vomited, passes through the bowels 



THE GENERAL MANAGEMENT OF CHILDREN. 3 I 

undigested, and the little creature starves to death in the 
midst of plenty, or dies from the ill effects of the constant 
presence of fermenting food in the alimentary canal. On 
these accounts many changes in diet, as to quality and quantity, 
must be anticipated and made. 

Important matters, therefore, to be studied in detail are : (a) 
the selection of a proper substitute for the breast milk ; (//) 
the quantity to be given ; (c) the method of modification ; 
(d) the mode of administration ; and (V) the means of preser- 
vation. 

(a) Healthy breast milk may be taken as the type of 
infants' food, and the nearer an artificial substance can be made 
to approach it in chemical composition and physical properties, 
the more perfect it is. 

Xormal breast milk has a specific gravity of 1.031. It is a 
persistently alkaline fluid, having a somewhat animal, usually 
disagreeable, and very rarely sweetish taste. It is bluish- 
white in color and thin and water}" in consistence. 

According to Leeds' analysis, its average composition is : 

Fat, 4.13 per cent- 

Mi'.k sugar (lactose), 7.00 " " 

Albuminoids, 2. CO " 

Salts, 0.20 ■• " 

Water, So. 67 " <•' 

Some authorities give a lower albuminoid average, namely, 

1.50 per cent. ; but as will be detailed later, the proportion of 
this ingredient varies great!}-, and it is safe to assert that a 
range from i.oo to 2.25 per cent, is perfectly normal. 

Human milk contains, then, fats, nitrogenous material, carbo- 
hydrates, salts, and water — all the elements essential to repair 
tissue waste, to supply new material for growth, and to main- 
tain bod}' heat, or, in other words, to constitute a perfect 
aliment ; and these, too, are so proportioned in the combina- 
tion as to most easily and complete!}- meet the demands. 



32 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

It must not be supposed, however, that the elements are 
uniformly present in the same proportion. On the contrary, 
the fluid varies both at different periods of lactation and in 
different individuals. 

This fact is the most striking feature of the above observer's 
work, which shows that the most changeable constituent is 
the albuminoids, varying from a maximum of 4.86 per cent, 
to a minimum of 0.85 ; the next are the fats and salts, the 
maximum being about three times the minimum ; and the 
least, the sugar. The latter, in fact, varies but little from a 
standard of about 7 per cent. The function of the albu- 
minoids is nutritive ; that of milk sugar calorifacient. Hence 
the point seems to be that nature, while allowing a wide 
range of oscillation in the rapidity of tissue building, care- 
fully provides an available fuel for the constant mainten- 
ance of animal heat ; the supply of caloric due to cerebral 
impulses and self-originated locomotion being extremely small 
in early infancy. 

In seeking a substitute for human milk, one naturally turns 
to the domestic animals for the source of supply. Between 
the milk of the ass, cow, goat, and ewe there is little choice, 
so far as composition is concerned, though, perhaps, asses' 
milk resembles that of women a little more closely than the 
others ; nevertheless, cows' milk is usually selected, because, 
being plentiful, it is easily obtained and cheap. 

Cows' milk * (market milk) has a specific gravity of 1.029, 
is richer looking — that is, whiter and more opaque — than 
human milk, and is slightly acid in reaction unless perfectly 
fresh from pasture -fed animals, when it may be neutral or 
alkaline, and contains : 



*The characters of cows' milk may be determined with sufficient accuracy in 
the following way : 

Provide a urinometer, such as shown in figure I. To obtain the specific gravity, 



THE GENERAL MANAGEMENT OF CHILDREN. 



33 



Fat, 3.75 per cent. 

Milk sugar (lactose), 4.42 

Albuminoids, 3 76 

Salts, 0.68 

Water, 87.39 

Comparing this analysis with that previously given for 
human milk, it is readily seen that the two fluids differ in 
specific gravity and reaction, and that cows' milk contains 
more nitrogenous material, but less fat and much less sugar 
than woman's milk. These differences and the general 
characteristics of the two fluids are very striking when 
tabulated * as follows : 



Reaction, . . . 
Specific gravity, 
Bacteria, . 
Fats, . . 
Lactose, . 
Albuminoids 
Ash (salts), 



Sound Dairy Milk. 

Feebly acid. 

I.0297 

Always present. 

3.0 to 6.0; average, 3.75 

3-5 to 5-5; " 4.42 
3.oto6.o; " 3.76 
0.6 to 0.9; " 0.68 



Woman's Mii.k. 

Persistently alkaline. 

1-0313 

Absent. 

2.0 to 7.0 ; average, 4.13 

5.4 to 7.9 ; " 7.00 

O.85 to 4 86 ; " 2.00 

O.13 to 0.37 ; " 0.20 



fill the beaker to such a point with milk that it will float the specific gravity glass, and 
read the degree of density from the scale at a level with 
the surface of the milk. The chemical reaction is found 
by inserting a piece of blue litmus paper, which should 
turn slightly red a few moments after being wet. In ap- 
plying this test small pieces of litmus paper should be 
examined under and in the milk, as exposure to air may 
redden paper dipped in milk though the flu'd itself may 
not be acid. To ascertain the proportion of cream, cut a 
narrow strip of paper four inches long, and divide the 
upper half-inch, by cross-markings, into twel e equal 
parts ; paste this on the beaker with the marked portion 
uppermost, and the lower edge coming accurately to the 
bottom of the beaker; then pour in enough milk to 
come just to the top of the paper, and place the whole 
aside for twenty-four hours. During this time the cream 
rises and appears as a yellow layer at the top ; this layer 
should have the depth of ten or twelve spaces. FlG 

* Leeds, "American Text-book of Diseases of Children." 
3 



QJ? 



-Lactometer. 



34 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

While the sugar of human and cow's milk is chemically 
identical, and the fats are quite similar, there are important 
differences in the quality as well as the quantity of the nitro- 
genous material. This in both fluids is complex, being made 
up of casein, lactalbumin, and peptones. The peptones are 
present in very small quantities only, and to what extent they 
exist naturally, and to what, in cow's milk, they are formed 
by bacterial action, is not known. 

Casein is an acid substance, and is present in combination 
with an alkali, chiefly as potassium caseinate. The casein of 
cow's milk is readily precipitated by dilute acid, and is thrown 
down in large firm masses ; that of human milk requires more 
acid and is precipitated in fine, soft particles, which are dis- 
solved by an excess of acid. After the separation of the 
casein, the lactalbumin is left in solution in the whey. Lac- 
talbumin closely resembles serum albumin, is unaffected by 
acid, but is precipitated by boiling. 

The relative proportions of casein and lactalbumin have 
been determined with sufficient accuracy to point out the most 
important of all the differences between the two secretions, 
which is, that the fraction of the total albuminoids in cow's 
milk which is coagulable by acids (casein) is far greater (per- 
haps four times) than the non -coagulable part (lactalbumin). 
In woman's milk, on the contrary, the reverse is true, and the 
non-coagulable part much exceeds (perhaps by more than 
twice) the coagulable portion. Taking weight for weight of 
each secretion, the coagulum of human milk is only one-fifth 
of that of cow's milk. 

This difference is readily tested by adding rennet to the two 
fluids. In the case of cow's milk the casein is coagulated 
into large, firm masses, while with human milk a light, loose 
curd is formed. In the stomach the acid gastric juice has the 
same effect, producing, in the first instance, a coagulum most 
difficult to digest ; in the other, one of vastly less bulk 



THE GENERAL MANAGEMENT OF CHILDREN. 35 

and readily attacked and broken down by the gastrointes- 
tinal solvents. 

These chemical and physical properties of cows' milk can 
be altered by various methods of preparation ; and unless this 
be done, there are few instances in which it will not prove a 
poor substitute for the natural food. 

Condensed milk is frequently recommended by physicians, 
and largely used by the laity on their own responsibility. It 
keeps better than cows' milk and is supposed to be more 
readily digested by young infants. The latter supposition is 
a mistaken one, and arises from the overlooked fact that con- 
densed milk is always given dissolved in a large proportion of 
water, while cows' milk is too frequently used insufficiently 
diluted or otherwise improperly prepared. The author is con- 
vinced of the accuracy of this statement from a number of 
years' close study of the subject. 

Condensed milk contains a large proportion of sugar, forms 
fat quickly, and thus makes large babies ; sugar also counter- 
acts the tendency to constipation — often a troublesome com- 
plaint in hand-feeding. These advantages are unquestioned, 
and, together with the ease of preparation and the fact that, 
when in good condition, it is a sterile fluid, are those which 
place it so high in the esteem of monthly nurses. It is equally 
true, however, that prepared as a food it does not contain 
enough nutrient material, either in the form of fat or of albu- 
minoids, to supply the wants of a growing infant. 

Again, more than half of the saccharine ingredient of this 
preparation is cane sugar, added for the purpose of preserva- 
tion, and this material is very liable, when in excess, to ferment 
in the alimentary canal, giving rise to irritant products that 
impede digestion. 

Infants fed upon condensed milk, though fat, are pale, leth- 
argic, and flabby ; although large, they are far from strong ; 
have little power to resist diseases ; often cut their teeth late, 



2,6 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

and are very liable to drift into rickets. It must be remem- 
bered, also, that condensed milk, when long kept or when 
packed in imperfect cans, not infrequently undergoes decom- 
position, and thus becomes utterly unfit for use. 

For a temporary change of diet, and as a substitute during 
traveling or under circumstances in which sound cows' milk 
cannot be obtained, it may be resorted to with advantage. 
Again, for feeding very young infants when a sterile food of 
low albuminoid percentage is indicated, it may sometimes 
prove useful, but the necessity of adding fat, in the form of 
cream, must always be insisted upon. 

The farinaceous substances so often selected, especially by 
the poor, to replace breast milk, not only are bad foods, but 
have both directly and indirectly a deleterious effect upon the 
processes of nutrition. They are bad for two reasons : First, 
they differ materially in chemical composition from human 
milk. For example, in arrow-root, which is the favorite, the 
proportion of the tissue-building to the heat-producing ele- 
ment is as one to twenty, while in human milk it is about 
one to five. Secondly, -the heat-producing principle, starch, 
must be converted into sugar before it can be absorbed. This 
change is accomplished in the body by the saliva and pan- 
creatic juice — secretions that are not fully established until 
the fourth month. 

While the starch lies undigested in the gastro-intestinal 
canal it is subject to fermentation, resulting in the formation 
of irritant products that rapidly induce catarrh of the mucous 
membrane — a condition directly interfering with the digestion 
and absorption of food. Again, perfect nutrition demands 
rapid waste and removal of effete tissues as well as repair of 
the same. This is effected by oxidation. Now, sugars are 
known to have a much greater affinity for oxygen than albu- 
minates, and when the diet consists of farinaceous material, 
the small amount of sugar formed and absorbed appropriates 



THE GENERAL MANAGEMENT OF CHILDREN. 37 

oxygen that otherwise would go toward the removal of waste, 
and so retards the necessary changes. The persistent and 
exclusive use of this class of food always leads to a condi- 
tion of malnutrition, which may result in simple atrophy, 
scurvy, or rickets, while the irritant products of fermenta- 
tion often produce sufficient gastro-intestinal disturbance to 
cause death. 

Farinaceous food, as such, is therefore never permissible 
before the later months of infancy, and then only as an 
adjunct to properly modified milk mixtures. Earlier, it may 
be employed, for its mechanical action, with milk mixtures, 
and in properly selected cases proves very useful in this way. 
The purpose of this method of employment will be con- 
sidered later. 

The nutrient value of the cereals and their products as 
they exist in so-called "infants' foods" has been imperfectly 
determined. They are undoubtedly useful as mechanical 
attenuants, but it is very certain that none of them, unless 
prepared with milk, can permanently meet the demands of 
nutrition. At the same time, it is quite probable that the 
albuminoids with the soluble carbohydrates (maltose) obtained 
by Liebig's process have a food value of their own, making 
them more serviceable than the starches. 

(p) The quantity of food to be allowed each day varies 
with the appetite and age. Some infants habitually eat little, 
others much ; as both thrive, the question of the correct 
amount in a given case must be answered by observation. 
So long as the child develops with normal rapidity and keeps 
well, he may be allowed to eat as much or as little as he 
wants ; for if food of proper strength be given at proper 
intervals, the instinctive cravings of hunger, since they 
represent the wants of the system, rarely lead to excess 
in either direction. Nevertheless it is well to have some 
guide. 



38 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

During- the first four weeks infants generally require from 
twelve to seventeen fluidounces of food ; in the second and 
third months, about thirty fluidounces ; and from this time to 
the twelfth month, from two to two and a half or even three 
pints. After the twelfth month the quantity depends upon 
whether additions be made to the diet, or milk food be used 
exclusively. When the daily amount reaches three pints, the 
limit of the capacity of the stomach is usually attained, and 
the greater demand for nutriment, as growth advances month 
by month, must be met by adding to the strength of the 
food rather than by increasing its bulk. These two factors, 
strength and quantity, are intimately associated throughout 
the whole period of infancy, and in the earlier months a mere 
increase in the latter is not always sufficient to maintain the 
balance of nutrition. 

As a rule, infants are overfed, and this opens the very 
interesting question of the normal capacity of the stomach at 
different ages. Rotch states that, by actual measurement, 
the stomach of an infant five days old holds 25 c.c, or 
six and a quarter fluidrachms, a quantity very far short of 
that usually forced upon the babe during the first, week. 
Frowlowsky's investigations show that there is a very rapid 
increase in the capacity of the stomach during the first two 
months of life, while in the third, fourth, and fifth months the 
increase is slight. 

Guided by these data, the quantity of food should be 
rapidly augmented during the first six or eight weeks of 
life and then held at the same quantity up to the fifth or 
sixth month. Another considerable increase is also de- 
manded between the sixth and the tenth months. 

The author has been unable to verify the above measure- 
ments, and has, on the contrary, found no uniformity in the 
size of the stomach for given ages ; still clinical experience is 
a sufficient guide, and upon this the following table is based : 



THE GENERAL MANAGEMENT OF CHILDREN. 



39 



TABLE OF INTERVALS OF FEEDING AND AVERAGE AMOUNTS 

OF FOOD. 



Age. 


Intervals of 
Feeding. 


Average Amount 
at Each Feeding. 


Average Amount in 
24 Hours. 


During first week, . . . 


2 hours. 


I ounce. 


12 ounces. 


From second to sixth 
week, .... . . . 


2 hours. 


\)/ z to 2 ounces. 


12 to 17 ounces. 


From sixth week to 
third month, .... 


2 hours. 


3 to 4 ounces. 


24 to 30 ounces. 


From third to sixth 
month, 


2y z hours. 


4 to 6 ounces. 


32 to 36 ounces. 


At ten months, .... 


3 hours. 


8 ounces. 


40 ounces. 



(c) The object to be accomplished in the preparation or 
modification of cows' milk is to make it resemble human 
milk as much as possible in chemical composition and physi- 
cal properties. To do this, it is necessary to reduce the pro- 
portion of albuminoids, to increase the proportion of fat and 
sugar, and to overcome the tendency of the casein to coagu- 
late into large, firm masses after entering the stomach and 
coming in contact with the acid gastric juice. 

Dilution with water is all that need be done to reduce the 
amount of albuminoids to the proper level ; but as this dimin- 
ishes the already insufficient fat and sugar, it is essential to 
add these materials to the mixture of milk and water. Fat is 
best added in the form of gravity cream ; and of the sugars, 
either pure white loaf sugar or sugar of milk may be used. 
The latter is greatly preferable, because it is the natural sugar, 
is directly assimilable, in the process of digestion is con- 
verted into lactic acid, and, unlike cane sugar, is not readily 
decomposed into alcohol and carbonic acid. 

Firm clotting may be prevented by the addition of an alkali 
or one of the attenuants. 

Lime water is the alkali usually selected. It neutralizes 



40 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

the slightly acid reaction which always characterizes market 
milk, and, to the extent of the quantity added, forms a solu- 
ble calcium caseinate, which is not decomposed by the acid 
gastric, juice with the precipitation of firm curds. In conse- 
quence, the total bulk of casein coagulum is diminished, and 
the ease of digestion increased. As lime water contains only 
half a grain of lime to the fluidounce, measurable results 
cannot be attained unless at least a third part of the milk 
mixture be lime water. The quantity often used — one or 
two teaspoonfuls to the bottle of food — has no effect beyond 
neutralizing the usual acidity of the milk itself. When lime 
water is constantly employed, it becomes quite an item of 
expense if procured from the drug shop ; this outlay is un- 
necessary, for it can be made quite as well in the nursery. 
Take a piece of unslaked lime as large as a walnut, drop it 
into two quarts of filtered water contained in an earthen 
vessel, stir thoroughly, allow to settle, and use only from the 
top, replacing the water and stirring as consumed. 

Instead of lime water, from five to fifteen drops of the 
saccharated solution of lime may be added to each bottle. 

This solution is made in the following way : 

Take of — 

Slaked lime, I ounce 

Refined sugar, in powder, 2 ounces 

Distilled water, I pint. 

Mix the lime and sugar by trituration in a mortar. Transfer the mixture to a 
bottle containing the water and, having closed this with a cork, shake it 
occasionally for a few hours. Finally, separate the clear solution with a 
siphon and keep it in a stoppered bottle. 

Attenuates are substances employed to act in the main 
mechanically by getting, as it were, between the particles of 
casein during coagulation, preventing their running together 
and forming a large, compact mass. This class embraces 
gummy materials like dextrin, gelatin, the various infants' 



THE GENERAL MANAGEMENT OF CHILDREN. 4 1 

foods prepared by Liebig's process (in which the starch of 
wheat and barley is converted into maltose and dextrin), and 
finely divided starch as it exists in barley or oatmeal water ; 
and it is for this purpose only that starch is permissible as an 
element of diet in infancy. Barley water and gelatin are the 
attenuants usually employed. 

To prepare barley water, put two teaspoonfuls of washed 
pearl barley, with a pint of cold filtered water, into a sauce- 
pan, boil slowly down to two-thirds, and strain. To be effi- 
cient, it must be used as a diluent instead of, and in the same 
proportion as, water. 

Gelatin is prepared in the following way : Put a piece of 
plate gelatin, an inch square, into a half-tumblerful of cold 
water, and let it stand for three hours ; then turn the whole 
into a teacup ; place this in a saucepan half full of water and 
boil until the gelatin is dissolved. When cold, this forms a 
jelly ; from one to two teaspoonfuls may be added to each 
bottle of milk food. 

When an ''infants' food" is used to act mechanically, care 
should be taken to select a reliable one — that is, one in which the 
starch has been converted into maltose and dextrin by the pro- 
cess of manufacture. The articles known as " Mellin's Food " 
and " Horlick's Food" can be relied upon. One teaspoonful 
of either, dissolved in a tablespoonful of hot water and added 
to each portion of food, makes a very easily digested mixture. 

It must not be inferred from what has been stated in regard 
to the use of lime water and attenuants, that these are essen- 
tials in the artificial feeding of infants. On the contrary, the 
majority of healthy babies require only sound cows' milk, 
properly modified by the addition of cream, milk sugar, and 
water. To the practical understanding of the proper methods 
of modification a schedule of the diet of a hand-fed infant 
from birth upward, with a sketch of the variations that have 
to be made most frequently, will serve as a useful guide. 
4 



42 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Diet during the first week : 

Cream, f^ij 

Whey, f 3 iij 

Water (hot), fgiij 

Milk sugar, gr. xx. 

For each portion ; to be given every two hours from 5 a.m. to II P.M., and 

in some cases once or twice at night ; amounting to twelve fluidounccs of 

food per diem. 

Diet from the second to the sixth week : 

Milk, f3 ss 

Cream, „ f 3 ij 

Milk sugar, gr. xx 

Water, f^j. 

Fur each portion ; to be given every two hours from 5 A.M. to 11 p.m.; 
amounting to seventeen fluidounces of food per diem. 

Diet from the sixth week to the end of the second month : 

Milk, fgj,.^ 

Cream, f^ ss 

Milk sugar, 3 ss 

Water, f Jj, f J5 i j . 

For each portion ; to be given every two hours ; amounting to thirty fluid- 
ounces per diem. 

Diet from the beginning of the third month to the sixth 

month : 

Milk, fgij 

Cream, , f J ss 

Milk sugar, gj 

Water, f 3 iss. 

For each portion ; to be given every two and a half hours, or thirty-two 
fluidounces per diem. 

Diet during the sixth and seventh months : 

Milk, f 3 iijss 

. Cream, f% ss 

Milk sugar, gj 

Water, fl'j- 

For each portion ; to be given every three hours from 6 or 7 A. M. to 9 or 10 
P.M. ; thirty-six fluidounces duly. 



THE GENERAL MANAGEMENT OF CHILDREN. 



43 



Often a pinch — gr. 2 to 5 — of table salt is of service, and 
may be added, after the second week, to each portion of food. 

A table of the dietary, so far as it has been carried, may be 
useful for convenience of reference : 



TABLE OF INGREDIENTS, HOURS AND INTERVALS OF FEEDING, 
AND TOTAL QUANTITY OF FOOD FOR A HEALTHY ARTI- 
FICIALLY FED INFANT FROM BIRTH TO THE END OF THE 
SEVENTH MONTH. 



Age. 


< 

O 


> 

a 

X 


Milk. 




Salt. 


a 

h 
< 


Hours 

for 

Feeding. 


Inter- 
vals of 
Feed- 
ing. 


Total 
Quantity. 


During first 
week. 


fS'L 


f 3 iij. 




gr- 

XX. 




f 3 "J 


5 A.M. to 
II P.M. ; 
some- 
times 1 
A.M. and 

3 A.M. 


2 
hours. 


15 xij. 


From second 
to sixth 

week. 


f3 j J 




f=ss. 


gr- 

XX. 


a 
pinch. 


f£- 


5 A.M. to 
II P.M. 


2 
hours. 


fgxvij. 


From sixth 
week to end 
of second 
month. 


f^ss. 




f 3 x. 


3 ss. 


a 
pinch. 


f o x - 


5 A.M. to 
II P.M. 


2 
hours. 


f 5 XXX. 


From third to 
sixth month 


fgss. 




faij- 


si- 


a 
pinch 


f^iss 


5 A.M. to 
IO.3O 
P.M. 


hours. 


f^ xxxij. 


During sixth 
and seventh 
months. 


f^ss 




f^iiiss. 


s'}- 


a 
pinch. 


fjij- 


7 A.M. to 
IO P.M. 


3 

hours. 


13 xxxvj. 



Throughout the eighth and ninth months five meals a day 
will be sufficient, each meal composed of: 

Milk, f^vj 

Cream, f^ ss 

Milk sugar, gj 

Water, f^iss. 

This allows forty fluidounces of food per diem. 



44 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

At this age it is sometimes advisable to supplement the 
milk mixture with one of the reliable " infants' foods " 
(Liebig's foods) ; thus, two teaspoonfuls of Mellin's food 
may be added to the second, third, and fourth meals, the 
milk sugar being then omitted. Instead of a Liebig's food, 
one of the wheat or barley flours prepared by baking or by 
diastase digestion may be used. Baking at a temperature of 
300 to 400 converts the starch into dextrin ; treatment 
with diastase produces maltose and dextrin. The best ex- 
amples of the baked flours are Blair's Wheat Food, Imperial 
Granum, and Robinson's Barley. In selecting a Liebig's 
food or a baked flour as an adjuvant, one must be influenced 
by the condition of the infant to be fed. A baked flour is 
indicated when there is a tendency to too frequent and liquid 
faecal evacuations, as it has a somewhat astringent action, and 
is to be avoided in cases of sluggish bowels and constipation. 
Under the latter conditions a Liebig's food — Mellin's, for 
instance — should be used, as a laxative action is desirable. 

Diet from the tenth to the fourteenth month, five meals 
daily : 

Milk, f^ vijss 

Cream, f^ ss 

Milk sugar, 3 j 

Water, f^iss. 

Here also a supplemental food — Mellin's or barley jelly * 
— often may be employed with advantage. 

Occasionally,- about the end of the first year, a more varied 
and substantial diet may be required ; for example : 

First meal, J a. m. — Milk mixture as above. 

Second meal, 10.30 a. m. — A breakfast-cupful (eight fluid- 
ounces) of milk, warmed. 

* Barhy Jelly. — Put 2 teaspoonfuls of washed pearl barley into a quart 
saucepan with a pint and one-half of water; boil slowly down to a pint ; strain, 
and allow liquid to set into a jelly. 



THE GENERAL MANAGEMENT OF CHILDREN. 45 

Third meal, 2 p. m. — The yolk of an e°;cr ligrhtlv boiled, 
with stale bread-crumbs. 

Four tli meal, 6 p. m. — Same as first. 

Fifth meal, 10 p. m. — Same as second. 

On alternate days the third meal may consist of a teacupful 
(six fluidounces) of beef-,* mutton-, f or chicken-broth, t con- 
taining a few stale bread-crumbs. 

Diet from the fourteenth to eighteenth month, five meals a 
day : 

First meal, 7 A. m. — A slice of stale bread, broken and 
soaked in a breakfast-cup (f§viij ) of new milk. Or two table- 
spoonfuls of well-cooked and strained porridge (oatmeal or 
cracked wheat), with two tablespoonfuls of cream and a little 
salt (no sugar) ; a breakfast-cupful (ff>viij) of new milk. 

Second meal, 10 a. m. — A teacupful (f§yj) of milk, with a 
soda-biscuit or a thin slice of lightly buttered bread. 

Third meal, 2 p. iff. — A teacupful (foyj) of beef-, chicken-, 
or mutton- broth, with a slice of bread ; one good table- 
spoonful of rice-and-milk pudding. 

Fourth meal, 6 p. iff. — Same as first. 

Fifth meal, 10 p.m. — A breakfast-cupful (foviij) of milk, 
with or without one tablespoonful of a good Liebig's food. 

To alternate with this : 



* Beef-broth. — Mince one pound of lean beef, put it, with its juice, into an 
earthen vessel containing a pint of water at 85- ° F.. and let it stand for one hour ; 
strain through stout muslin, squeezing all juice from the meat ; place this liquid 
on the fire, and, while stirring briskly, slowly heat just to the boiling-point : then 
remove at once and season with salt. 

^Mutton-broth. — Add one pound of loin of mutton to three pints of water: 
boil gently until very tender, adding a little salt; strain into a basin, and. when 
cold, skim off fat. "Warm when serving. 

i Chicken-broth . — A small chicken, or half of a large fowl, thoroughly cleaned 
and with all the skin and fat removed, is to be chopped, bone and all, into small 
pieces ; put them, with salt, into a saucepan, and add a quart of boiling water; 
cover closely and simmer over a slow fire for two hours : after removing, allow 
to stand, still covered, for an hour ; then strain through a sieve. 



46 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

First meal, 7 a. m. — The yolk of an egg lightly boiled, with 
bread-crumbs and salt ; a teacupful (fSyj) of milk. 

Second meal, 10 a. m. — A teacupful (fSyj) of milk, with a 
thin slice of lightly buttered bread. 

Third meal, 2 p. m. — A mashed baked potato moistened 
with four tablespoonfuls (f §ij) of meat-broth ; two good table- 
spoonfuls of junket with cream. 

Fourth meal, 6 p. m. — A breakfast-cupful (fgviij) of milk, 
with a slice of bread broken up and soaked in it. 

Fifth meal, 10 p. m. — A teacupful (f§vj) of milk. 

The fifth meal is often unnecessary, and sleep should never 
be disturbed for it. Should the child awake at 5 or 6 A. m., 
he should break his fast upon a cup of warm milk, and not 
go hungry until the set breakfast hour. 

Diet from eighteen months to two and a half years, five 
meals daily : 

First meal, 7 a. m. — A breakfast-cupful (fgviij) of new milk ; 
the yolk of a lightly boiled egg with a little butter and salt ; 
two thin slices of bread and butter. 

Second meal, 1 1 a. m. — A teacupful (f§vj) of milk, with a 
soda-biscuit. 

Third meal, 2 p. m. — A breakfast-cupful (fgviij) of beef-, 
mutton-, or chicken-broth ; a thin slice of stale bread ; a 
saucer of rice-and-milk pudding. 

Fourth meal, 6.30 P. m. — A breakfast-cupful (f§viij) of milk, 
with bread and butter. 

To alternate with this : 

First meal, 7 a. m. — Four good tablespoonfuls of well- 
cooked porridge (oatmeal or cracked wheat), with two table- 
spoonfuls of cream and a little salt (no sugar) ; a teacupful 
(fSyj) of milk. 

Second meal, 1 1 A. m. — A teacupful (f§vj) of milk, with a 
slice of bread and butter. 

Third meal, 2 p. m. — One tablespoonful of underdone 



THE GENERAL MANAGEMENT OF CHILDREN. 47 

mutton pounded to a paste ; bread and butter, or mashed 
potatoes, moistened with good, plain dish-gravy ; a saucer of 
junket. 

Fourth meal, 6.30 p. m. — A breakfast-cupful (f§viij | of milk ; 
a slice of soft milk-toast, or a slice or two of bread and butter. 

Diet from two and a half to three and a half years, four 
meals daily : 

First meal, 7.30 a. m. — One or two tumblerfuls (foviij) of 
milk ; a saucer of thoroughly cooked oatmeal or wheaten 
grits, and one or two slices of bread (one day old) and butter. 

Second meal, 11 a.m. (if hungry). — A tumblerful (f§viij) of 
milk, or a teacupful (f§vj) of meat-broth, with a biscuit. 

Third meal, 2 p. m. — A slice of underdone roast beef or 
mutton, or a bit of roast chicken or turkey, minced as fine as 
possible ; a baked potato thoroughly mashed with a fork and 
moistened with gravy ; a slice or two of bread and butter ; a 
saucer of junket or rice-and-milk pudding. 

Instead of the potato, well-boiled rice or plainly dressed 
macaroni may be allowed for variety, or one well-cooked 
green vegetable — i. e. spinach, celery, young onions, cauli- 
flower, and young peas mashed with a fork. 

Fourth meal, 7 p. m. — A tumblerful (f§viij ! of milk : one or 
two slices of bread and butter or of well-moistened milk-toast ; 
a baked apple, or stewed prunes or apples. 

An important point, often neglected, is the matter of drink. 
Even the youngest infant requires water several times daily, 
and the demand increases with age. The water must be as 
pure as possible and should not be too cold. In the heat of 
summer, however, -water moderately cooled by ice may be 
allowed without harm. 

The foregoing schedule must, of course, be regarded only 
as an average. Many children can bear nothing but milk 
food up to the age of two or even three years, and, provided 
enough be taken, no fear for their nutrition need be entertained. 



48 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

If a child be thriving on milk, he is never to be forced to take 
additional food merely because a certain age has been reached ; 
let the healthy appetite be the guide. 

Much more difficulty is experienced in feeding infants dur- 
ing the first twelve months than during the second ; it will 
be well, therefore, to consider what would best be done in 
case the food described should disagree. 

If, after feeding, vomiting occur, with the expulsion of large, 
firm clots of casein, the effect of adding lime water or barley 
water must be tried. 

For instance, at the age of six weeks, make each bottle of: 

Milk, fgj, fgij 

Cream, f,^ ss 

Milk sugar, % ss 

Lime water, f Jj, fgij. 

Or of: 

Milk, fgj, fgij 

Cream, f % ss 

Milk sugar, gss 

Barley water, . . . • f"3J, fgij. 

Sometimes, particularly if there be diarrhoea, boiling makes 
the milk more tolerable, and in this condition it may be used 
instead of fresh milk in either of the above mixtures. Con- 
densed milk, too, can be employed temporarily, making each 
portion of: 

Condensed milk, gj 

Cream, f3 ss 

Hot water, f^iiss. 

" Stoppings " is another good substitute for cows' milk. 
It is obtained by re-milking the cow after the ordinary daily 
supply has been drawn, and contains much cream and but 
little curd. Assimilable proportions of this are : 

Stoppings, fgj 

Water, f.^ij. 



THE GENERAL MANAGEMENT OF CHILDREN. 49 

And if the small amount of casein in such a mixture be 
still undigested : 

Strippings, f ^ iss 

Barley water, f 3 iss. 

Another good food is that recommended by Dr. A. V. Meigs. 
It consists of a combination of two parts of the cream, con- 
taining from fourteen to sixteen per cent, of fat ; one part 
average milk ; two parts lime water, and three parts sugar 
water, the latter consisting of seventeen and three-fourths 
drachms of milk sugar to one pint of water. This makes an 
alkaline mixture with the percentage of its ingredients closely 
corresponding to human milk. 

When, in spite of careful preparation, all of these foods 
give rise to indigestion with fever, and the expulsion, by 
vomiting and diarrhoea, of hard curds from the stomach and 
intestines, the expedient of predigesting the milk must be 
resorted to. 

Predigestion or peptonization is best accomplished by the 
action of pancreatin. That manufactured under the name 
of extractum pancreatis, by Fairchild Brothers & Foster, of 
New York, has proved most efficient in my hands. 

It is sometimes necessary to carry the artificial process 
almost or quite to complete digestion of the casein ; more 
frequently, partial predigestion is sufficient. 

For the first, put into a clean quart bottle five grains of 
extractum pancreatis and fifteen grains of sodium bicarbonate 
(the contents of a "peptonizing tube "), with four fluidounces 
of cool, filtered water ; shake thoroughly together, and add 
a pint of fresh, cool milk. Place the bottle in water, not so 
hot but that the whole hand can be held in it for a minute 
without discomfort, and keep the bottle there for exactly 
thirty minutes. At the end of that time put the bottle on ice 
to check further digestion and to keep the milk from spoiling. 



Fhe fluid obtained, while somewhat ess white iri color than 
milk, ires not differ from it in taste ; if, however, an acid be 
added, the casein, instead of being coagulated into large 
firm curds, takes the form of minute, soft flakes, or readily 
broken-down feather} - masses of small size. When the 
process : : just tc the point described, the casein is 

rly :.:. : : nverre i ::::: :e:::::e : ;:: ever -.:: -. . finr 
nen: :: ::r.tir_uei "ar:.:h ^:-::i :ke ?.n".:ur.: ::" casein 
:. peptonization is complete Then the liquid - i ish- 
yellow in color, has a distinctly bitter taste, and shows no 
coagulation whatever on the addition of an acid. This 
artificial digestion, therefore, may be carried just as far as 
circumstances indicate although it is ordinarily res: to stop 
it short of complete conversion, as children object to the 
markedly bitter taste, and often, on account of it, absolutely 
refuse the food. Partial peptonization, to: . is usually sufficient 
:: aiar-r :ke : ::.. : :: re ;-.--. "ilit::r_. 7: s:::e :::e rr:cer 

moment for arresting the process, the person conducting it 
re: :s: be told to taste the milk from time to time, and as soon 
as the least bitterness - :oreciable^ to remove the bottle 
: : : n: :::: h :: ^:er :.: i : '.;. :: i: v: : :: ire f; : : : :iir r ?.r i : :se 
Such milk may be sweetened with -gar of milk, and given 
':.:: :: :_i : i :e :.::: 7 : r :-.;-. ..:: :-:/.: :: six -veeks :?.: 
meal may consist of: 

:::::: ::i ::: •: '" 

. '.-- -: s:;i: " ; - ; 

Wite - . ■'- 

To this, cream may be added whence- : le -nd by dimin- 
- .^ :::: . :.: ::" -varer ar.i i::cre^sir.r :::.-.: :•:" :::.".-: :.".e 
s:rer.r::: ""the :::d :.:. : -- rr.:.ie rre = :er ;.: =::y 'in:e 

Although ever}- precaution be taker, the last of a quantity 
of predigested food is very apt to grow bitter; and if the 
attendants will take the trou: le : much better to peptonize 
ever} - meal separately. This is readily done by obtaining a 



THE GENERAL MANAGEMENT OF CHILDREN. 5 I 

number of powders of pancreatin and bicarbonate of sodium, 
so proportioned that each packet shall contain the proper 
amount for one bottle of food. 
For example : 

& . Extract, pancreatis, gr. ix 

Sodii bicarb., gr. xxiv. 

M. et ft. cbait. No. xii. 
Sig. — Put one powder into a nursing bottle with two fluidounces of filtered 

water and two fluidounces of fresh sweet milk ; shake together and keep 

warm in a water-bath for about half an hour before feeding ; sweeten with 

half a teaspoonful of milk sugar. 

Partial predigestion is the most useful and most uniformly 
applicable of all the methods of modifying cows' milk for 
infants having feeble digestive powers. For this purpose I 
have employed for the past ten years the material known as 
Fairchild's " peptogenic milk powder." This powder contains 
a digestive ferment, pancreatin ; an alkali, bicarbonate of 
sodium ; and a due proportion of milk sugar. It is in no 
sense an "infants' food," and as a considerable heat (i I 5 F.) 
is required to insure its action, the food prepared by it is not 
only partially predigested, but also, to a certain extent, 
Pasteurized — an end greatly to be desired under certain 
conditions, as will be detailed later. 

The mode of employment is as follows : 

Take of — 

Milk, fjij 

Water, f 3 ij 

Cream, ^ ss 

Peptogenic milk powder, gj (a level teaspoonful). 

This mixture is heated over a brisk flame to a point that 
can be comfortably sipped by the preparer (about 1 1 5 ° F.), 
kept at this heat, with constant stirring, for six minutes, and 
then quickly cooled to the proper temperature (98 ° F.) for 
administration. In preparing each bottle separately — by far 



52 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

the better plan — the mixture should not be heated to the boil- 
ing-point, as this checks the action of the pancreatin, and all 
digestive action after ingestion is lost. On the other hand, 
when the whole supply for a day is prepared at once, the re- 
quired bulk of powder for the quantity of milk mixture is 
added, and the whole is heated slowly to boiling, ten minutes 
being occupied, and then quickly cooled. Here the object is 
to stop the digestion, so that the portion to be used later in 
the day may not be fully peptonized and bitter. This method 
has the advantage of effecting more perfect Pasteurization. 
When properly prepared, the resultant, so-called " humanized 
milk" presents the albuminoids in a minutely coagulable and 
digestible form ; has an alkaline reaction ; contains the proper 
proportion of salts, milk sugar, and fat ; is not bitter in taste ; 
has the appearance of human milk, and by Leeds' analysis 
shows : 

Water, 86.2 per cent. 

Fat, 4.5 

Milk sugar, 7. " 

Albuminoids, .2. " 

Ash (salts), 0.3 " 

This corresponds very closely with Leeds' average analysis of 
human milk. 

The great advantages of partial peptonization are that the 
necessity for lime water, barley water, and thickening sub- 
stances to keep apart the curd is done away with, and that, 
when the digestive disturbance requiring a careful preparation 
of food is removed, an ordinary milk diet can be gradually 
resumed by regularly diminishing the time artificial digestion 
is allowed to progress. This changes the casein in a less 
and less degree, until, finally, it is taken in its natural form. 

As milk exists in the healthy cow's udder it is aseptic, but 
during milking and subsequent handling and transportation it 
often becomes contaminated by various foreign materials, both 



THE GENERAL MANAGEMENT OF CHILDREN. 53 

organic and inorganic, which either are apt to set up some 
injurious change in the fluid before ingestion, or give rise to 
various disturbances after entering the alimentary canal. 
Again, if the cows themselves be unhealthy, their milk may 
carry disease germs. The germs most frequently present 
are the saprophytic bacteria, potent in the production of diar- 
rhceal disorders ; the bacillus tuberculosis ; and the germs of 
cholera, diphtheria, scarlet and typhoid fevers : all of which 
are readily taken up by and flourish in milk at ordinary 
temperatures. To deprive these accidentally introduced 
organic impurities of their activity the milk must be subjected 
to "sterilization." It must be insisted here that this process 
is a preventive, and in no sense a therapeutic measure ; that it 
is not to be recommended when one can be sure of the purity 
of the milk supplied and of the conditions for its preservation ; 
and that milk so treated must be modified according to the age 
and demands of the individual case in the usual way. Steriliza- 
tion may be conducted either at a high or a low temperature. 

Sterilization at a High Temperature (21 2° F.). — Several 
admirable implements have been devised for conducting the 
process ; one of the most simple, made after a design of my 
own, is shown in figure 2. 

This apparatus is made of tin, and consists of an oblong 
case provided with a well-fitting cover, and having a movable 
perforated false bottom (d), which stands a short distance 
above the true one and has attached a framework capable of 
holding ten six-ounce nursing bottles. On the outside of the 
case is a row of supports (b) for holding bottles inverted 
while drying, and at the proper distance below these a gradu- 
ally inclining gutter (c) for carrying off the drip. A movable 
water bath (a) is hung to the side ; in this each bottle of 
food may be heated at the time of administration. 

The bottles are made of flint glass and are graduated ; the 
graduated markings being especially convenient for measure- 



54 



DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 



ment and rendering the use of a separate measuring glass 
unnecessary, a matter of no little moment, as every imple- 
ment that comes in contact with the milk in sterilization must 
be kept chemically clean. Ten bottles are used, so that the 
whole supply of milk intended for a day's consumption can 
be prepared at once. Each bottle is provided with a perfor- 
ated rubber cork, which in turn is closed by a well-fitting 
glass stopper. 

Sterilization should be performed in the morning as soon as 




Fig. 2.— Author's Sterilizer. 



possible after the milk has been served. The process is as 
follows : First, see that the ten bottles are perfectly clean and 
dry; pour into each six fluidounces (12 tablespoonfuls) of 
milk ; insert the perforated rubber corks — without the glass 
stoppers, however ; remove the false bottom and place the 
bottles in the frame ; pour into the case enough water to fill 
it to the height of about two inches ; replace the false bottom 
carrying the bottles ; adjust lid, and put the whole on the 



THE GENERAL MANAGEMENT OF CHILDREN. 55 

kitchen range. Allow the water to boil, and, by occasion- 
ally removing the lid, ascertain that the expansion that imme- 
diately precedes boiling has taken place in the milk ; then 
press the glass stoppers into the perforated corks, and thus 
hermetically close each bottle. After this, keep the appa- 
ratus on the fire, and the water boiling for twenty minutes. 
Finally, remove the false bottom with the bottles ; pour out 
the water, replace, and carry the whole, covered with the lid, 
to the nursery. 

When the hour of feeding arrives, put one of the bottles 
into the attached water-bath and heat it to the proper point 
for administration. The milk must, of course, be diluted 
with filtered water, and receive the additions ordinarily made 
to adapt it to children of different ages. The tip used — and 
a tube must not be employed even here — should be thor- 
oughly cleaned, and immersed for a few moments in boiling 
water before it is attached to the bottle. 

So soon as a bottle is emptied — and if the whole of its con- 
tents be not taken, the remainder must be thrown away — it is 
washed in the ordinary manner with a solution of bicarbonate 
or salicylate of sodium (one teaspoonful of either to a pint of 
water) and placed in the rack (b) to drain and dry. 

Milk sterilized by the above process will remain sound for 
several days — according to some authorities, as many as 
eighteen — when the heating is continued for thirty minutes, 
and still longer if protracted for an hour and a half. It is 
especially useful in traveling, when fresh milk cannot be 
obtained ; for use in cities during the heat of summer, when 
milk is most apt to undergo injurious changes ; for a tempo- 
rary change of food for delicate children, or for those suffering 
from diseases of the stomach or intestinal canal. But the 
experiments of Leeds show that sterilization at the boiling- 
point of water causes the following modifications : Casein is 
rendered less coagulable by rennet, and is acted on slowly 



56 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

and imperfectly by pepsin and pancreatin ; proteid matters 
attach themselves to fat globules, and probably bring about a 
less perfect assimilation of fat ; while milk sugar, by pro- 
longed heating, is completely destroyed. Koplik states that 
" from the temperature of 75 ° C. upwards, there is a separa- 
tion of the serum-albumin of the milk ; the casein loses its 
coagulability to rennet, and at 85 ° C. amounts of rennet 
which for the raw condition of the milk are found sufficient to 
act, cease to be effective." On account of these alterations 
produced by prolonged subjection to a high temperature, milk 
so sterilized is difficult to digest, and many infants do not 
thrive upon it, become constipated, are badly nourished and 
anaemic, and sometimes develop scurvy. 

The problem, therefore, that presents itself in the sterili- 
zation of milk for infants' food is to devise a method which shall 
efficiently destroy the contained germs, and yet in the least 
possible degree interfere with its ready digestion and its 
nutritive qualities. This is best accomplished by : 

Sterilization at a Low Temperature, or Pasteurization. — 
Hueppe considers that from a physiological standpoint milk 
is best sterilized under a temperature of 75 ° C. (167 F.), 
while other experimenters have shown that temperatures 
lower than ioo° C. (21 2° F.), if continued for a short time, 
will destroy a very large proportion of the germs, and will 
destroy with certainty many pathogenic germs which find 
their way into milk either from the cow or as external con- 
taminations. The elaborate experiments of Yersin, Granchier, 
Lidoux-Libard, and Bitter show that the bacillus tuberculosis 
in milk will be destroyed in ten minutes by an exposure to 
75 C. (167 F.), in fifteen minutes to 70 C. (158 F.), and 
in thirty minutes to 68° C. ( 1 54. 5 ° F.). Concerning other 
bacteria, Van Geuns found that a few seconds' exposure to 
6o° C. (140 F.) would kill the cholera spirilla, the Finkler- 
Prior bacillus, the typhoid bacillus, and the pneumococcus. 



THE GENERAL MANAGEMENT OF CHILDREN. 



57 



It may, therefore, be concluded that a temperature of not 
less than 158 F. will render milk sufficiently germ-free for 
infant food. It is also certain that a temperature of less than 
176 F. produces no alterations in the composition of milk 
that affect its digestibility. 

Methods of Pasteurizing milk in bulk have been brought 
forward both in Germany and in this country, and now the 
procedure has been brought down to an easily managed 
system for household use. This depends upon the fact that 
the temperature of the milk to be treated may be raised to 




Fig. 3.— Freeman's Pasteurizer. 



about the desired point (167 F.) by immersing a certain 
definite quantity of milk in a properly proportioned bulk of 
boiling water, the source of heat having been removed. The 
apparatus consists of two parts — a graduated pail for the 
water and a receptacle for the bottles of milk. This recep- 
tacle consists of a series of seven or ten hollow zinc cylinders 
fastened together, which fits into the pail containing the 
boiling water. Each of these cylinders is large enough to 
hold one of the bottles of milk, the series of seven cylinders 
5 



58 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

accommodating seven eight-ounce bottles, and the series of ten 
cylinders being intended for ten six-ounce bottles. When the 
bottles, stopped with cotton corks, are in place, water is 
poured around them to secure perfect conduction of the heat. 
After the water in the pail is thoroughly boiling, it is removed 
from the stove and placed on a non-conducting surface. The 
cylinders are now introduced, and the pail covered and left 
standing for thirty minutes, after which the milk is rapidly 
cooled by placing the bottles in a refrigerator or immersing 
them in cold water. A convenient apparatus for nursery use 
is Dr. Freeman's Pasteurizer, shown in figure 3. 

The apparatus consists of a pail for water and a receptacle for the bottles of milk. 
The flat/ is a simple affair with a cover. Extending around it is a groove for indi- 
cating the level to which it is to be filled with water ; inside are three supports 
(c) for holding the receptacle. The receptacle for the bottles consists of a number 
of hollow cylinders fastened together and surrounded by a wire (a), which rests 
on the support (c) when the milk is being heated. Below the wire (a) are three 
short wires (b); these rest on the supports (c) when the receptacle is raised for 
cooling. 

The steps of the process are as follows : 

Fill the pail to the level of the groove with water, cover it, and put it on the 
stove to boil, the receptacle for the bottles having been left out. Fill the body of 
each bottle with milk or some modification of milk in proper proportion for feed- 
ing; stopper with a wad of cotton-batting and put in a refrigerator. If all the 
bottles which the receptacle holds are not needed, fill the remaining cylinders with 
cold water. When the water in the pail on the stove boils thoroughly, take the 
bottles of milk from the refrigerator and put them in the spaces in the receptacle. 
Pour cold water into each of these spaces so as to surround the body of the bottle. 
Take the pail of boiling water from the stove and put it on a table or mat ; not on 
metal or stone. Be sure that the pail is still filled exactly to the level of the 
groove and that the water is boiling vigorously. Put the receptacle containing 
the bottles of milk into the pail of boiling water, so that the wire (a) will rest on 
the support (c), cover the pail quickly and let it stand forty-five minutes. During 
this period the pail must not be on the stove and the cover must not be removed. 
Now uncover the pail and lift the receptacle and turn it so that the wire (b) will 
rest on the support (c), thus elevating the top of the receptacle above that of the 
pail. Put the whole in a basin under a faucet to which a rubber pipe may be 
attached connecting it with the pail. The water will overflow from the pail into 
the basin. Or the pail may be placed under a pump, fresh cold water being 
pumped into it every few minutes. When, however, it is not possible to cool the 



THE GENERAL MANAGEMENT OF CHILDREN. 59 

milk in this way, place the receptacle containing the bottles in iced water, or stand 
the bottles on wood in a refrigerator. To warm the milk for use, put the bottle 
containing it in a vessel of cold water on the stove, and leave it until it is warm. 
Use a fresh bottle for each feeding. Wash the bottles thoroughly after using, and 
once a day put all the empty bottles in a kettle of cold water on the stove and let 
this water boil for an hour. The bottles should then be taken out and placed 
bottom up until used. 

A sufficiently perfect apparatus may be readily improvised. 
All that is required is a bottle rack similar to that of the 
Arnold sterilizer, and a tin pail large enough to receive the 
rack and bottles and provided with a well-fitting cover. In 
conducting the process fill the bottles, previously perfectly 
cleaned, with milk and stop them with cotton ; place them in 
the rack, and this in turn in the pail ; pour into the pail enough 
boiling water to come up to the level of the milk in the bottles, 
adjust the cover, and let the whole stand on a wooden table 
until the water becomes cool — twenty to thirty minutes ; lastly, 
place the bottles in a refrigerator. 

Pasteurized milk so prepared and placed in a refrigerator 
will keep perfectly sound and sweet for twenty-four hours at 
least. Its advantage as a food lies in its sterility, and, like 
ordinary milk, it must be modified by the addition of water, 
cream, and milk sugar to meet the special demands of each 
case. The various milk mixtures are often sterilized, the 
method being the same as for pure milk. 

Within the past ten years Dr. Rotch, of Boston, has intro- 
duced a method of preparing cows' milk for the artificial 
feeding of infants which has for its object a recombination of 
the fat, proteids, and lactose of. the milk, and the production 
of a mixture having a composition identical with human milk, 
or one of any desired percentage of these three essential 
ingredients. The resultant food is called " modified milk"; 
but since cows' milk has been modified in the nursery for 
years past by the addition of water, sugar, cream, and various 
other less suitable materials, it will be termed here laboratory 



60 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

milk or percentage milk. For its production laboratories 
have been established in several leading cities of this country 
where a physician, upon sending a prescription indicating the 
percentages required, may have the mixture compounded, 
and whence the food is sent daily to the consumers. Per- 
centage milk is composed of centrifugal cream of 16 per cent, 
fat-strength (usually), separated milk from which practically 
all fat has been removed by the centrifugation of the cream, 
20 per cent, sugar of milk solution, sterilized lime water, and 
distilled water. After combination in the total quantity neces- 
sary for a day's feeding, the mixture is divided into as many 
portions as there are to be feedings and these are poured into 
sterilized nursing bottles, which are stopped with cotton. If 
so desired, the mixture is sterilized either at a high or low 
temperature. The day's supply is now ready to be delivered 
to the consumer in convenient baskets. 

Properly prepared laboratory milk food has certain readily 
recognized advantages. The original milk is obtained from 
carefully selected and kept stock ; it is milked from the cow 
by clean, often gloved, hands, and due care is taken in the 
cooling and subsequent treatment to prevent the introduction 
of gross or microscopic foreign matter. Again, to insure 
still further an aseptic food, each day's supply is Pasteurized 
or sterilized before it is sent to the infant ; and, if it must be 
shipped a long distance, it is packed in ice, and thus kept at 
a temperature unfavorable to fermentation or other injurious 
change. The same care for absolute cleanliness is also 
observed with the apparatus used in preparing the food and 
with the bottles in which it is served. The food comes to the 
infant ready to be administered, except that it must be warmed, 
and the labor of home preparation is avoided. The infant 
receives from day to day a food which is uniform in quantity 
(each feeding being sent in a separate bottle) ; has an identical 
percentage of fat, sugar, and proteids, and a fixed alkalinity. 



THE GENERAL MANAGEMENT OF CHILDREN. 



61 



Laboratory milk being prescribed, it is possible for the physi- 
cian to supply an artificial food identical in chemical composi- 
tion with normal human milk, and at the same time to vary 
at will and accurately the percentages of fat, sugar, and pro- 
teids to meet the demands of each infant's digestive powers 
and developmental requirements. 

In prescribing, a special blank is used and filled out as 
desired by the physician ; for example, a prescription for a 
child of two months should read : 



R. Fat 

Milk sugar, . . 
Albuminoids, 
Mineral matter, 
Total solids, . . 
Water, .... 



Per Cent. 



3 SO 
6 So 



Remarks. 



Number of feedings 
Amount at 



each feeding 
Infant's age 
Infant's weight 

Alkalinity ..A??. 

Heat at I r S . s .°.. K . 



3 Yz Jluidounc.es. 
2 months. 

i o pounds. 



Ordered for 



Baby B. 



Addn 



Date, 

Month and day 



1901. 



Signature. 



M.D. 



Experience with this method has been sufficiently extended 
to warrant the following tabulation of average percentages 
and quantities for healthy infants at different ages : 



62 



DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 



THEORETICAL BASIS FOR FEEDING A HEALTHY INFANT 
(Walker-Gordon Laboratory.) 



Wkeks 


&8 


Percentages. 


Weeks 


H N 

go 


Percentages. 


OF 


g 








OF 


g 








Life. 


Is 


Fat. 


Sugar. Pro 


eids. 


Life. 


'Jo 


Fat. 


Sugar. 


Proteids. 


ist, . . . 


*# 


2.00 


4.50 


75 


27th, . . 


5 l A 


4.00 


6.50 


* -75 


2d, . . . 


1% 


2.50 


5-50 1 


00 


28th, 




5% 


4.00 


7.00 


i-75 


3d, • • • 


2 


3.00 


6.00 1 


00 


29th, 




5% 


4.00 


7.00 


1-75 


4th, . . . 


2 1 / 


3.00 


6.00 1 


00 


30th, 




5K 


4.00 


7.00 


'•75 


5th, . . . 


2 % 


3-25 


6.50 1 


00 


3ist, 




6 


4.00 


7.00 


1-75 


6th, . . . 


3 


3-25 


6.50 1 


25 


32d, . 




6 


4.00 


7.00 


'■75 


7th, . . . 


3 , 


3-50 


6.50 1 


25 


33d, . 




^ 


4.00 


6.50 


i-75 


8th, . . . 


3tf 


3 50 


6.50 1 


25 


34th, 




fhi 


4.00 


6.50 


2.00 


9th, . . 


ZV2 


3-50 


6.50 1 


25 


35th, 




ey A 


4.00 


6.50 


2.00 


ioth, . . 


3'A 


3-50 


6.50 1 


25 


36th, 




&A 


4.00 


6.50 


2.00 


nth, . . 


z% 


3-50 


6.50 1 


25 


37th, 




t>y 2 


4.00 


6.50 


2.00 


12th, . . 


3 3 A 


3-50 


6.50 1 


25 


38th, 




6% 


4.00 


6.50 


2.00 


13th, . . 


Z% 


3-5° 


6.50 1 


25 


39th, 




ey 2 


4.00 


6.50 


2.00 


14th, . . 


4 , 


3-50 


6.50 1 


25 


40th, 




6% 


4.00 


6.50 


2.00 


15th, . . 


4 H 


3-75 


6.50 1 


25 


41st, 




&A 


4.00 


6.50 


2.00 


16th, . . 


4* 


3-75 


6.50 1 


25 


42d, . 




7 


4.00 


6.50 


2.00 


17th, . . 


4^ 


3-75 


6.50 1 


50 


43^, - 




7 


4.00 


6.50 


2.25 


i 8th, . 


4^ 


3-75 


6.50 1 


50 


44th, 




7 


4.00 


6.00 


2.50 


19th, . . 


4K 


3-75 


6.50 1 


50 


45th, 




7 


4.00 


6.00 


2.50 


20th, . . 


4 3 /i 


3-75 


6.50 1 


50 


46th, 




7X 


4.00 


6.00 


2.50 


2ISt, . . 


4K 


3-75 


6.50 1 


50 


47th, 




7% 


4 00 


6.00 


2.50 


22d, . . . 


5 


3-75 


6.50 1 


50 


48th, 




7Va 


4. GO 


6.00 


2.50 


23d, . . . 


5 , 


3-75 


6.50 1 


50 


49th, 




7% 


4.00 


6.00 


2-75 


24th, . . 


5* 


3-75 


6.50 1 


75 


50th, 




7% 


4.00 


6.00 


2-75 


25th, . . 


5 H 


3-75 


6.50 1 


75 


5ist, 




7% 


4.00 


6.00 


2-75 


26th, . . 


5^ 


3-75 


6.50 1 


75 


52d, . 




7% 


4.OO 


5-50 


3.00 



The figures tabulated above should be taken as averages 
only ; they are too high for infants that are not in perfect 
health both as to digestive power and development. How- 
ever, each case must be considered on its own merits, per- 
centages prescribed accordingly, and when a suitable formula 
has been attained, the food may be increased in strength as 
rapidly as digestion permits. 

Dr. L. Emmett Holt gives the following rules for altera- 
tions in the percentages : " If not gaining in weight, with- 
out special signs of indigestion, increase the proportion of 
all the ingredients ; if habitual colic, diminish the proteids ; 
for frequent vomiting soon after feeding, reduce the quantity ; 
for the regurgitation of sour masses of food, reduce the fat, 
and sometimes also the proteids ; for obstinate constipation, 
increase both fat and proteids." 



THE GENERAL MANAGEMENT OF CHILDREN. 63 

With all these advantages, laboratory milk is theoretic- 
ally the most perfect substitute for normal human milk that 
science has yet devised. But, unfortunately, clinical experi- 
ence does not bear out this theory. 

Since the establishment of a milk laboratory in Philadelphia 
I have thoroughly tested this method of artificial feeding, with 
very unsatisfactory results. Of a large number of infants so 
fed there were a few that thrived under the exclusive use of 
percentage milk from shortly after birth up to the time of 
beginning a mixed diet, a larger class in which the method 
was partially satisfactory, and a much larger one in which it 
was quite unsatisfactory. 

In the partially satisfactory class laboratory milk was used 
for a considerable period — six months to a year — without 
producing active illness, but gradually inducing health condi- 
tions necessitating a change of food. 

The symptoms indicating an unhealthy condition were very 
uniform: viz., pallid, dry skin; dry, lusterless hair; flabby, 
soft muscles ; indifferent appetite ; inactive — not decidedly 
constipated — bowels, with clay-colored evacuations ; light- 
colored urine ; listlessness and disinclination to play ; peevish- 
ness and restless sleep — in a word, the features of malnutri- 
tion. With the muscle flabbiness there was not always 
emaciation, but the two conditions were often associated, and 
the little sufferer was both weak and puny. 

The instances of the totally unsatisfactory group were by 
far the most numerous, and in it, in my experience, may be 
placed the vast majority of infants fed upon laboratory milk 
after the first eight weeks of life. It embraces those cases in 
which laboratory milk feeding must, of necessity, be discon- 
tinued on account of the onset of some acute disorder of un- 
doubted dietetic origin. The disorders observed in my cases 
were in some instances infantile scurvy, but most frequently 
acute gastro-intestinal catarrh, indicated by pyrexia, vomiting, 



64 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

and diarrhoea with the expulsion of curds and greenish mucus 
or large quantities of greenish serum. 

The question now naturally arises, Why should a food 
capable of being prescribed to approach so nearly breast milk 
in chemical composition, so uniform in its make-up, so sterile, 
and so easily and accurately varied to meet digestive emerg- 
encies, fail when put to a clinical test ? 

My answer is that in its composition all the fat is removed 
by a separator, and the food as prepared for the infant is a re- 
combination of this fat and an alkaline solution of the proteids 
and sugar. In a word, the natural emulsion is destroyed. 
This, I think, in some way lessens the digestibility of the pro- 
teids and leads either to conditions of malnutrition or to an 
irritative diarrhoea with the expulsion of the undigested pro- 
teids in the form of compact curds — and this, too, despite 
changes in the proportion of the proteids ; for the partially 
starved children are attacked with vomiting or diarrhoea with 
fever if the percentage of proteids be increased (say to 2.00 
per cent, at ten months), and those having irritative diarrhoea 
are not benefited until the percentage is cut down to a starva- 
tion point (0.75 per cent, in a child of three months still 
showed numerous curds in the evacuations). What a contrast 
to normal breast milk, an emulsion having 1.5 to 2 per cent, 
of proteids ! 

I have never seen an infant from two to ten months of age 
able to satisfactorily digest a laboratory mixture of stronger 
proteid percentage than 1.50, and have often seen cases of 
two months and more unable to digest a percentage of 0.50. 

On the other hand, how does it stand with the cream, milk, 
sugar of milk, and water mixture made at home by capable 
heads and careful hands? These mixtures are still modified 
milk mixtures ; but their basis is unseparated milk, a natural 
emulsion containing fat, proteids, sugar, and salts. Under 
this physical condition the proteids are much more easily 



THE GENERAL MANAGEMENT OF CHILDREN. 65 

digested, so that a badly nourished child of ten months, for 
whom the proteid percentage of laboratory milk cannot be 
forced higher than 1.50, will easily digest and grow strong 
upon a domestic mixture of : 

Cream (16 per cent. ), ...f5ss\ / ^ , „ . H 

■ . v ^ ; r- Fat ' 3.75 per cent. 

Milk, f x vss f \ c o 

• > = Sugar, 4.84 " 

Milk sugar, Zi I ) v, . • ■, „ „ ,, 

& ' ° I I Proteids, 2.Q7 " 

Water, f^ij. / \ 

And an infant of two months having an irritative diarrhcea 
on a starvation diet of O.50 per cent, proteids, will begin to 
improve and soon grow strong and well on : 



Cream (16 per cent.), . . .f^ss 
Milk, . f^x 



Fat, 4.00 per cent. 

Sugar, 6.15 " 



MilksU S ar ' 3J Proteids, 2.09 

Water, f^ iss / \ 

In domestic modification, of course, the same care must be 
taken to secure clean, pure milk and cream from healthy, 
well-kept cows. This is quite possible now in Philadelphia, 
and in other cities of the country, and is becoming easier 
each year, as more attention is being given to infant feeding 
and greater demand is being made for a pure milk supply. 
Pasteurization is as readily done in the nursery as in the 
laboratory. Accurate measurement of quantities and cleanli- 
ness of vessels and feeding bottles is equally possible and, in 
my experience, quite as certain at home as in the shop. 

The milk and cream from a dairy may vary slightly in 
chemical composition from day to day, but this variation 
seems to me to be a minor detail, perhaps of hygienic advan- 
tage, and certainly of questionable importance when compared 
with the separator's destruction of the physical properties of 
the basal milk. One certainly should not sacrifice every- 
thing to chemical accuracy. 

These statements must not be understood as condemning 



66 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

laboratory milk absolutely. If its introduction has done 
nothing else, it has greatly advanced substitute infant feeding, 
by fixing the attention of the profession upon the importance 
of cleanliness and accuracy in the quantity and chemical com- 
position of cows' milk foods, and by placing the whole ques- 
tion upon a higher scientific plane than it had ever reached 
before. Further, laboratory milk is of great use in feeding 
infants who must be artificially nourished from birth, and may 
often (about 20 per cent, of cases) be advantageously em- 
ployed up to the end of the second month, and is better at 
any age than the haphazard mixtures employed by careless 
and untrained mothers or nurses. At the same time, like 
every other single plan of preparing artificial food for infants 
(sterilization for instance), its applicability is limited, and much 
more so, in my experience, than the process of home modifi- 
cation, in which unseparated milk is employed. 

The ordinary home modification of whole milk by the 
addition of cream, milk sugar, and water, while most suc- 
cessful clinically, is, as already stated, comparatively inaccu- 
rate. It is quite possible, though, to apply the principles of 
the milk laboratory in the nursery if the attendant be intelli- 
gent and appreciative of the importance of absolute cleanli- 
ness in manipulation. Dr. Thompson S. Westcott has de- 
vised a series of formulae for home modification which yield 
very accurate results ; they are best detailed in their author's 
own words : 

"A careful study of the principles of percentage feeding 
has shown that milk mixtures can be prepared with the same 
accuracy as is secured in laboratory modification by using 
whole milk in combination with creams of 16 per cent., 20 
per cent., and, very exceptionally, 32 per cent, fat-strength. 
Sugar is supplied in definite percentage also in the form of 
varying quantities of dry sugar of milk, which is to be dis- 
solved in the required amount of diluent before combination 



THE GENERAL MANAGEMENT OF CHILDREN. 6j 

of the three ingredients. The following symbols are readily 
understood : 



F == desired percentage of fat. 


C = 


quantity 


of cream in ounces 


P = " " " proteids. 


M = 


4 i 


" milk " " 


S = " " , " sugar. 


Q = 


" 


" total mixture 
ounces. 




w= 


t I 


" water in ounces. 


• 


L = 


a 


" sugar of milk 
ounces. 



"The fournecessary formulae are as follows 



c- (F ~ P 



2.4 or 16.8 or 29.2 

M = ^-? —4 or 5 or 8 X C. 

4 
L _ QXS — (4C + 44M) 

100 

W = Q — (M + C) 

" In practice the desired percentage formula is first decided 
upon and the total quantity of the mixture for the day, or 
for the bottle, is determined. The corresponding quantities 
of cream, milk, sugar, and water are then found by substituting 
these values in the formulae and working out the indicated 
mathematical processes. 

" For example, required the quantities of 16 per cent, 
cream, whole milk, milk sugar, and water or other diluent to 
give 40 ounces of mixture containing fat, 3.50 per cent., pro- 
teids, 1.50 per cent., and sugar, 6 per cent. 

" By substituting these values for the corresponding sym- 
bols in the formulae we obtain : 

C = (3-5Q — I-5Q) X 40 __ 2 X 40 __ _So_ _ ^ oz 

12.4 12.4 12.4 "^ 

M = 40^50 _ 4 6 4 = 35 _ 6 = Qz 

4 
L = 40 X 6 — (4 X 64 + 4.4 X 9-4) _ r 3/ oz 

100 ^ 
W = 40 — (9.4 -4- 6.4) = 24.2 oz. 



*Westcott: "The Scientific Modification of Milk." International Clinics, 
October, 1900. When 16 per cent, cream is used, 12.4 and 4 are to be used in 
the cream and milk formulae, respectively. So, also, 16. 8 and 5, or 29.2 and 8, 
are to be used when 20 per cent, cream or 32 per cent, cream, respectively, is 
required. 



68 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

"In certain combinations of percentages it will be found 
that the value of M works out as a minus quantity. This in- 
dicates that the cream chosen is of too low a percentage, and 
a higher cream (20 per cent, or 32 per cent.) must be used, 
with which the formulae give satisfactory values. Ordinarily 
16 per cent, cream may be used for any proteid percentage 
above 1.00, and even for 0.75 with fat percentages up to 3.33. 
The 32 per cent, cream is required only for mixtures contain- 
ing less than 0.50 per cent, proteids with fat percentages 
above 3.125. It will also be observed that if the fat per- 
centage is lower than the proteid percentage the cream 
formula works out a negative value, which indicates that a 
skimmed milk must be used to supply the proteid percentage 
in excess of the fat percentage. Under such circumstances 
other formulae appropriate to the conditions must be em- 
ployed.* In practice, however, it is very unusual to make 
the fat percentage lower than that of the proteids, so that this 
contingency will rarely present itself. 

" A distinct advantage of this method is that if the quantity 
of cream be kept constant and the milk gradually increased, 
the total quantity of mixture being kept constant, both the 
proteid and fat percentages are gradually increased by an equal 
increment. When the fat value surpasses 4.00, beyond which 
it is rarely desirable to go, a drachm of cream may be dropped 
for each half ounce of milk added, the total quantity being- 
kept constant by adding water. By this means the strength 
of food may be gradually increased without necessitating fre- 
quent recalculation of the formula." 

Sometimes milk, in every form and however carefully pre- 
pared, ferments soon after being swallowed, and excites vom- 
iting, or causes great flatulence and discomfort, while it affords 
little nourishment. With these cases the best plan is to with- 
hold milk entirely for a time and try some other form of food. 
The following are good substitutes for an infant from three to 
six months old : 



* Loc. cit. 



THE GENERAL MANAGEMENT OF CHILDREN. 69 

1. Whey,* fgij 

Barley water, f 3 ij 

Milk sugar, gj (i teaspoonful). 

For one portion, to be given every two hours. 

2. Barley-jelly, f^j (1 teaspoonful) 

Water, f^iv. 

Mix and add half the white of a fresh egg. 
For one portion, to be given every two hours. 

3. Veal brothf (j4 lb- of meat to a pint of water), 
Barley water, of each, f^ij. 

For one portion, to be given every two hours. 

4. Raw-beef juice,! f .^ j— ij. 

Every two hours. 

While on No. 4 the patient must take from 12 to 24 fluid- 
ounces of pure water, barley water, or white-of-egg water 
each twenty-four hours ; these must be given in small doses 
at short intervals. 

Such foods are only to be used temporarily until the ten- 
dency to fermentation within the alimentary canal ceases ; 
then milk maybe gradually and cautiously resumed. 

When infants approaching the end of the first year become 
affected with indigestion, it is often sufficient to reduce the 
strength and quantity of the food to a point compatible with 
digestive powers. For instance, at eight months the food 
may be reduced to that proper for a healthy child of six 



* Whey. — Heat one pint of milk to a point that can be agreeably borne by the 
mouth; add, with gentle stirring, 2 teaspoonfuls (f^ij) of Fairchild's essence of 
pepsin ; let stand until firm coagulation takes place ; beat with a fork until the 
curd is finely divided ; strain. 

f Veal Broth. — Mince ^ to I pound of lean veal; pour upon it a pint of 
cold water ; let it stand for three hours, then slowly heat to boiling-point; after 
boiling briskly for two minutes, strain through a fine sieve and season with salt. 

{ Raw-beef Juice. — Take one pound of sirloin of beef, warm it in a broiler be- 
fore a quick fire, cut into cubes of about one-quarter of an inch, place in a lemon- 
squeezer or a meat-press, and forcibly express the juice ; remove the fat that 
rises to the surface after cooling. Never actually cook the meat. 



70 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

months, or even less. Here, too, predigestion of the food is 
very serviceable. 

If a few grains of extractum pancreatis be added to a goblet- 
ful of thick, well-boiled starch gruel, at a temperature of ioo° 
F., the gelatinous mucilage quickly grows thinner, and soon 
is transformed into a fluid, the starch having been rendered 
soluble by the action of the pancreatin ; by still longer con- 
tact, the hydrated starch is converted into dextrin and grape 
sugar. Advantage may be taken of this property to render 
the foods containing starch assimilable. Thus, to a mixture 
of barley jelly and milk, e. g. : 

Barley jelly, g ij 

Milk sugar, 3J 

Warm milk, . ■. . f,f viij ; 

add three grains of extractum pancreatis, and five grains of 
bicarbonate of sodium, and keep warm for half an hour before 
administering. 

The same process may be employed with food containing 
oatmeal, arrowroot or wheaten flour, with a view of convert- 
ing the starchy ingredients into digestible elements without 
materially altering the taste. 

When the infant has arrived at an age to take meat broths, 
these, too, when digestion is enfeebled, may be readily pep- 
tonized. 

{d) Success in hand-feeding depends upon proper adminis- 
tration as well as careful preparation of the food. 

From birth up to such time as broth, bread, and eggs are 
added to the diet, all the food should be taken from a bottle. 
Even after this, as the bottle is a comfort and insures slow 
feeding, it may be allowed for milk preparations, until the 
child, of his own accord, tires of it. The only feeding appa- 
ratus to be admitted to the nursery is the simple bottle and 
tip. All complicated arrangements of rubber and glass tub- 
ing are not only an abomination, but a fruitful source of sick- 



THE GENERAL MANAGEMENT OF CHILDREN. J 1 

ness and death. Rather than use them, it is far better to feed 
the infant with a spoon. The graduated nursing bottle first 
suggested by myself is a useful implement. Its interior sur- 
face is so shaped as to present no angles for the collection of 
milk ; it is easily cleaned, and the graduated scale is conve- 
nient for nursery use. It is made of transparent flint glass, 
so that the slightest foulness can be detected at a glance, and 
varies in capacity from six to twelve fluidounces. Two 
should be on hand at a time, to be used alternately. Imme- 
diately after a meal the bottle must be thoroughly washed 
out with scalding water, filled with a solution of bicarbonate 
or salicylate of sodium, — one teaspoonful of either to a pint 
of water, — and thus allowed to stand until next required ; 
then, the soda solution being emptied, it must be thoroughly 
rinsed with cold water before receiving the food. The tips or 
nipples, of which there should also be two, must be com- 
posed of soft, flexible india-rubber, and a conical shape is to 
be preferred, as being more readily everted and cleaned ; the 
opening at the point must be free, but not large enough to 
permit the milk to flow in a stream without suction. At the 
end of each feeding the nipple must be removed at once from 
the bottle, cleansed externally by rubbing with a stiff brush 
wet with cold water, everted and treated in the same way, 
and then placed in cold water and allowed to stand in a cool 
place until again wanted. 

While taking these precautions for perfect cleanliness, the 
nurse must satisfy herself of their efficacy by smelling both 
the bottle and the tip just before they are used, to be sure of 
the absence of any sour odor. 

Next to cleanliness of the feeding apparatus, it is important 
to insist upon the separate preparation of each meal immedi- 
ately before it is to be given. The practice of making, in the 
morning, the whole day's supply of food, though it saves 
trouble, is a most dangerous one. Unless subjected to 



J2 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Pasteurization or sterilization, changes almost invariably take 
place in the mixture, and by the close of the day it becomes 
unfit for consumption. 

When the graduated bottle is not at hand, a common glass 
graduate, marked for fluidrachms and ounces, and holding a 
pint, should be provided for the nursery. Some moments 
before mealtime, so as to avoid hurry, measure the different 
fluid ingredients of the food in this, one after the other ; add 
the requisite quantity of milk sugar, and mix the whole thor- 
oughly by stirring with a spoon, and pour into the feeding 
bottle. When the graduated bottle is employed, thorough 
shaking is sufficient. The food must now be heated to a 
temperature of about 95 ° F. This can be done by steeping 
the bottle in hot water, or by placing it in a water-bath over 
an alcohol lamp or gas jet. Finally, apply the tip and the 
meal is ready. 

When feeding, the child must occupy a half-reclining posi- 
tion in the nurse's lap. The bottle should be held by the 
nurse, at first horizontally, but gradually more and more 
tilted up as it is emptied, the object being to keep the neck 
always full and prevent the drawing in and swallowing of air. 
Ample time — say five, ten, or fifteen minutes, according to 
the quantity of food — should be allowed for the meal. It is 
best to withdraw the bottle occasionally for a brief rest, and 
after the meal is over, sucking from the empty bottle must 
not be allowed, even for a moment. 

(e) For children residing in cities, an honest dairyman 
must be found, who will serve sound milk and cream from 
country cows once every day in winter, and twice during the 
day in the heat of summer. The farm should be so situated 
that the consumer may be served not later than twelve hours 
after milking. The milk of ordinary stock is more suitable 
than that from Alderney, Durham, Jersey, or fancy bred cows, 
as in these the proportion of fat percentage is either too low or 



THE GENERAL MANAGEMENT OF CHILDREN. 73 

too high, varying from 2.88 to 5.21 per cent. The mixed milk 
of a good herd is to be preferred to that from a single animal. 
It is less likely to be affected by peculiarities of feeding, and 
less liable to variation from alterations in health or different 
stages of lactation. 

The care of the herd and of the milk is of great conse- 
quence. The cows should be subjected to the tuberculin test, 
their condition of health should be guaranteed by careful and 
regular inspection by a competent veterinarian, and the milk 
of any animal failing to pass should not be mixed with that 
from healthy animals. The cows must not be fed upon swill 
or the refuse of breweries, glucose factories, or any other 
fermented food. They must not be allowed to drink stagnant 
water, and must not be heated or worried before being milked. 
The pasture must be free from noxious weeds, and the barn 
and yard and the animals themselves must be neat. The 
udder should be washed before the milking, and the hands 
and clothing of the milkers and dairy workers should be kept 
clean, and the same aseptic precautions must be observed with 
cans, pails, and every implement with which the milk comes 
in contact. 

The milk must be at once thoroughly cooled. This is 
best accomplished by placing the can in a tank of cold spring 
water, or in ice -water, the water being the same depth as the 
milk in the can. It is well to keep the water in the tank 
flowing ; indeed, this is necessary unless ice-water be used. 
The can should remain uncovered during the cooling and the 
milk should be gently stirred. The temperature should be 
reduced to 45 ° F. within an hour, and the can must remain in 
the cold water until the time for delivering. 

In summer, when ready for delivery, the top should be 
placed in position and a cloth wet in cold water spread over 
the can, or refrigerator cans may be used. A better plan still 
is to serve the milk in glass jars having air-tight tops. At no 



74 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

season should the milk be frozen, and at the same time no 
buyer should receive milk having a temperature over 65 ° F. 

When the milk and cream are not served in sealed glass 
jars, it is well to provide two sets of small cans ; one set to 
be thoroughly cleansed and aired while the other is taken 
away by the milkman to bring back the next supply. So 
soon as this arrives in the morning, or in the morning, and 
evening in hot weather, the milk should be emptied into 
separate and absolutely clean earthenware or glass vessels 
with secure tops, and these put at once into a refrigerator 
reserved exclusively for them. This may stand in some con- 
venient spot near the nursery, but not in it, and especially not 
in an adjoining bath room. With a good refrigerator there is 
no difficulty in keeping milk perfectly sweet for twenty-four 
hours in winter and for twelve hours in summer, except on 
intensely hot days ; then it may be necessary to Pasteurize 
the whole of the supply when received, in order to prevent 
change. 

As already indicated, milk is a fluid having active powers 
of absorption, and frequently acts as the medium for the trans- 
mission of the contagion of such diseases as scarlatina, diph- 
theria, and typhoid fever. Dr. V. C. Vaughan and other 
chemists have also discovered in milk a special poison which 
is termed tyrotoxicon (cheese poison). 

The clinical element of interest in this discovery is the 
close analogy between the symptoms produced by the experi- 
mental use of tyrotoxicon and those observed in cholera 
infantum — an analogy suggestive of the probability of the 
latter disease being due to poisoned milk. This causal relation 
is borne out by certain well-known features of the disease. 
Thus, the affection occurs at a season when decomposition of 
milk takes place most rapidly ; it occurs at places where 
absolutely fresh milk cannot be obtained ; it prevails among 
classes of people whose surroundings are most favorable to 



THE GENERAL MANAGEMENT OF CHILDREN. 



/ D 



fermentative changes ; it is most fatal at an age when there is 
the greatest dependence upon milk as a food, when the gastro- 
intestinal mucous membrane is most susceptible to irritants. 
and when irritation and fever are most easily produced. 

Childhood. — Children who have cut their milk teeth may 
be fed for a twelvemonth — namely, up to the age of three and 
a half years — in the following way : 

First meal, 7 a. m. — One or two tumblerfuls of milk, a 
saucer of thoroughly cooked oatmeal or wheaten grits with 
cream and salt, and a slice or two of bread and butter. 

Second meal, 1 1 a. m. (if hungry). — A tumblerful of milk 
or a teacupful of broth with a biscuit. 

Third meal, 2 p. m. — A slice of underdone roast beef or 
mutton or a bit of roast chicken or turkey, minced as fine as 
possible ; a baked potato thoroughly mashed with a fork and 
moistened with gravy, or one well-cooked green vegetable, as 

O ^ ' DO-' 

spinach, young peas mashed with a fork, stewed celery ; 
bread and butter; a saucer of junket or rice-and-milk pud- 
ding. 

Fourth meal, 7 p. m. — A tumblerful of milk and one or two 
slices of well-moistened milk toast. 

Orange juice, apple scraped with a spoon, ripe peaches, and 
cooked fruit not oversweetened may be allowed, especially if 
there be a tendency to constipation. 

From three and a half years up the child must take his 
meals at the table with his parents, or with some reliable at- 
tendant who will see that he eats leisurely. The diet, while 
plain, must be varied. The following list will give an idea of 
the food to be selected : 

breakfast. 

Every Day. One Dish Oxly Each Day. 

Milk. Fresh fish. Eggs, plain omelette. 

Porridge and cream. Eggs, lightly boiled. Chicken hash. 

Bread and butter. " poached. Stewed kidney. 

" scrambled. " liver. 



?6 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Sound fruits may be allowed before and after the meal, according to taste, as 
oranges, grapes without pulp (seeds not to be swallowed), peaches, thoroughly 
ripe pears, cantaloupes, and strawberries. 



DINNER. 
Every Day. Two Dishes Each Day. 

Clear soup. Potatoes, baked. Hominy. 

Meat, roasted or broiled, " mashed. Macaroni, plain, 

and cut into small Spinach (puree). Peas, 

pieces. Stewed celery. String-beans, young. 

Bread and butter. Cauliflower. Green corn, grated. 

All green vegetables. 

Junket, rice-and-milk or other light pudding, and occasionally ice-cream, may 
be allowed for dessert. 

SUPPER. 
Every Day. 
Milk. 

Milk toast or bread and butter. 
Stewed fruit, baked apple. 

Fried food and highly seasoned or made-up dishes are to 
be excluded, and no condiment but salt is to be used. 

Eating, however little, between meals, must be absolutely 
avoided. Keep a young child from knowing the taste of 
cakes or bonbons, or, having learned it, let him feel that they 
are as unattainable as the thousand other things beyond his 
reach, and he soon ceases to ask for them. Even a piece of 
bread between meals should be forbidden. His appetite then 
remains natural, and he will eat proper food at his regular 
meal hours. 

Filtered or spring water should be the only drink ; tea, 
coffee, wine, or beer being entirely forbidden. 

As to the quantity, a healthy child may be permitted to 
satisfy his appetite at each meal, under the one condition that 
he eats slowly and masticates thoroughly. 

In case of illness, the diet must be reduced in quantity and 
quality according to the rules that are applicable to adults. 



THE GENERAL MANAGEMENT OF CHILDREN. 'J J 

2. Bathing. 

During the first two and a half years of life a child ought 
to be bathed once every day. The bath should be given at 
a regular time, and it is best to select some hour in the early 
morning, midway between two meals — ten o'clock, for in- 
stance. The tub should be placed near the fire or in a warm 
room in winter, and away from currents of air in summer. It 
should contain enough water to cover the child up to the 
neck when in a reclining posture, and the temperature must be 
about 95 F. Upon undressing the child, the first step is to 
wet his head ; then he is to be plunged into the water and 
thoroughly washed with a soft rag or sponge, and pure, 
unscented castile soap. After remaining in the water from 
three to five minutes the surface must be well dried, and 
rubbed with a flannel cloth or soft towel ; then the body 
must be enveloped in a light blanket and the infant either 
returned to his crib to sleep, or kept in the lap for ten or 
fifteen minutes, until thoroughly warm and rested, and finally 
dressed. If there be repugnance to the bath, the tub may 
be covered over with a blanket, and the child being placed 
upon it, may be slowly lowered into the water without seeing 
anything to excite his fears. 

In very hot weather, in addition to the morning full bath, 
the body may be sponged twice daily with water at a tem- 
perature of 90 F.; this, contrary to what might be expected, 
has a greater and more permanent cooling effect than bathing 
with cold water. 

After the third year, three baths a week are quite sufficient. 
An evening hour is now to be preferred, but the water must 
still be heated to 90 . 

About the tenth year cooler baths can be begun, from J 2 ° 
to 75 being the proper temperature. The cold sponge or 
cold plunge is not admissible as a daily routine until youth is 
well advanced. 



yS DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

The hot bath — 95 ° to 100 — is employed for various pur- 
poses, notably for a derivative action ; to cause diaphoresis, to 
relieve nervous irritability, and to promote sleep. Whether a 
full bath or merely a foot-bath be required, five minutes is a 
sufficient time for immersion ; then, with or without drying, 
according to the degree of sweating desirable, the whole body, 
or only the feet and legs in case of a foot-bath, must be 
enveloped in a blanket and the child put to bed. To render 
these baths more stimulating, from a teaspoonful to a table- 
spoonful of mustard flour maybe added, and the child held in 
the water until the arms of the nurse begin to tingle. 

It is important not to continue a hot bath too long, lest the 
primary stimulating effect be followed by depression. Cold 
baths, by shocking the system, first produce depression ; but 
this is temporary, and is followed by reaction, during which 
the skin grows red, and the pulse becomes fuller and stronger. 
They have, therefore, a general stimulant and tonic action, 
promoting nutrition and giving tone to the body. On account 
of the shock, the extent of which depends directly upon the 
coldness of the water, these baths must be used with caution, 
and are not to be employed in very young or feeble subjects. 

When giving a cold bath, the child must be stripped in a 
warm room, and thoroughly rubbed with the palm of the hand 
until the whole body, especially the spinal region, is reddened ; 
he must then stand in a tub containing enough hot water to 
cover the feet and be rapidly sponged with the cold water. 
The temperature of the latter must never be below 6o°, and the 
addition of half an ounce of sea-salt or a tablespoonful of con- 
centrated sea water to the gallon renders it more stimulating 
and insures a complete reaction. After the sponging, the sur- 
face must be thoroughly and quickly dried with a soft towel 
and shampooed with the open hand until aglow. 

The cooled bath may be employed with advantage in ex- 
treme conditions of hyperpyrexia. The child is first immersed 



THE GENERAL MANAGEMENT OF CHILDREN. 79 

in water at 95 °, and this is gradually lowered to yo° by the 
addition of cold water, the process occupying from fifteen to 
thirty minutes. 

Various medicated baths are employed. Of these, the most 
useful are : 

The Mtistard Bath. 

Take from two drachms to one ounce of powdered mustard ; hot water, two 
to four gallons. 

Derivative in form of foot-bath ; stimulant as general bath. 

Salt-water Bath. 

Take two ounces of rock salt, or Ditman's sea-salt, or concentrated sea-w T ater 
(best) ; water (hot or cold, according to season), four gallons. 

General bath, to be used every morning in chronic tuberculosis, scrofula, 
rickets, and general debility. Bath to be followed by thorough rubbing of the 
surface, especially over the spine. 

Bran Bath. 

Take one pint of bran, tie up in a muslin bag, place in a quart of water, boil 
for an hour, squeeze bag thoroughly into the. water ; add to four gallons of warm 
water. 

Useful in eczema and skin diseases. 

Nitro-muriatic Acid Bath. 

Take muriatic acid, one fluidrachm ; nitric acid, two fluidrachms; warm 
water, four gallons. 

Serviceable in hepatic sluggishness. Make bath in a wooden tub. May be 
employed as a foot or general bath. 

Mercurial Bath. 

R . Hydrarg. chlorid. corros., gr. v 

Alcohol., f^ij 

Aq. dest., f^j. M. 

S. — Add to four gallons of water. Employed in syphilitic skin diseases. 

Soda Bath. 

Take half an ounce of bicarbonate of sodium ; warm water, four gallons. 
Used in skin affections. 



8o DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

3. Clothing. 

Infants and young children have little power of resisting 
cold, and on this account require warm clothing. Too much 
cannot be said in condemnation of the fashion of allowing 
children to go, even while in the house, with bare legs and 
knees. 

Every child is supplied with a certain amount of nerve force 
to be daily expended in the maintenance of the different func- 
tions of the body — respiration, circulation, digestion, calorifi- 
cation, etc. If an excessive proportion of this force be con- 
sumed in keeping up the heat of the body, as is the case 
when so much is left bare, the other functions, especially the 
digestive, must suffer in consequence. During the oppressive 
heat of summer, the legs may be left uncovered ; but through- 
out the rest of the year, the whole body must be encased 
in woolen underclothing. The thickness of this must vary, 
of course, with the season. Providing this be done, the outer 
clothing may be left to the taste of the mother ; but all 
garments should fit loosely, that the functions of the different 
viscera may not be impeded by pressure. 

The best pattern of a winter night-dress is a long, plain slip, 
with a drawing-string at the bottom to prevent exposure of 
the feet and limbs, should the child kick off the bed-covering. 
This should be made of flannel, or of the more easily washed 
Canton flannel. In summer, a loose muslin one may be put 
on, without the drawing-string. A flannel under-vest should 
always be worn at night, light gauze in summer and heavier 
wool in winter ; care must be taken, however, to have one for 
night alone, discarding that worn in the daytime. 

For infants under a year old, a broad flannel abdominal ban- 
dage, extending from the hips well up to the thorax, or, 
better still, a knitted worsted band shaped to fit the form, is 
very useful in keeping the abdominal organs warm, aiding 
digestion, and preventing pain. 



THE GENERAL MANAGEMENT OF CHILDREN. 51 

All clothing should be changed sufficiently frequently to 
insure cleanliness. 

Shoes must be large, well shaped, and made of soft leather, 
with pliable soles, so as to allow the feet to grow freely. 

When dressing a child for exercise in the open air in cold 
weather, the outer clothing must not be put on until just 
before leaving the house, and removed immediately on return. 

It is important to protect the head from cold in winter by a 
close-fitting, thick cap ; and from the direct rays of the sun in 
summer by a broad-brimmed, light straw hat. 

Rubber shoes are necessary in wet weather to keep the feet 
warm and dry while walking out of doors. 

4. Sleep. 

For some time after birth infants spend the intervals 
between being fed, washed, and dressed in sleep, and thus 
pass fully eighteen out of the twenty-four hours. As age 
advances, the amount of sleep required becomes less, until at 
two years thirteen hours, and at three years eleven hours, are 
enough. Any marked diminution in the length of sleep, or 
decided restlessness, indicates disease, and demands attention 
from the physician. This matter, though, is perhaps more a 
question of training than any other item of nursery regimen, 
and many a mother, by want of judicious firmness, has ren- 
dered the early years of her child's life not only a burden to 
himself, but an annoyance to the entire household. 

One cannot too soon begin to form the good habit of regu- 
larity in sleeping hours, and, so far as circumstances will 
admit, the following rules may be enforced : 

From birth to the end of the sixth or eighth month the 
infant must sleep from 1 1 p. m. to 5 a. m., and as many hours 
during the day as nature demands and the exigencies of feed- 
ing, washing, and dressing will permit. 

From eight months to the end of two and a half years a 
7 



82 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

morning nap should be taken, from 12 m. to 1.30 or 2 p. m., 
the child being undressed and put to bed. The night's rest 
must begin at 7 p. m. If a late meal be required, the child 
can be taken up at about ten o'clock ; but if past the age for 
this he may sleep undisturbed until he wakes of his own 
accord, some time between 6 and 8 A. m. 

From two and a half to four years, an hour's sleep may or 
may not be taken in the morning, according to the disposition 
of the subject ; but in every case the bed must be occupied 
from 7.30 p. m. to six or seven o'clock on the following 
morning. 

After the fourth year few children will sleep in the daytime ; 
they are ready for bed by 8 p. m., and should be allowed to 
sleep for ten hours or more. 

A later retiring hour than 8.30 p. m. ought not to be en- 
couraged until after the twelfth or fifteenth year. 

When feasible, different rooms should be used for the day 
nursery and the sleeping apartment. The latter should be 
large, airy, well ventilated, so situated as to be exposed for a 
certain period each day to the direct rays of the sun, and pro- 
vided with an open fire-place, — for wood, preferably, — which 
serves for both heating and ventilating. It should contain a 
bed for the nurse and a crib for the child, and be without 
curtains, heavy hangings, or superfluous furniture. A station- 
ary washstand draining into a sewer is not to be permitted in 
the room, neither should it communicate with a bath-room. 
Soiled diapers or chamber utensils are to be removed at once, 
no matter what the time of night. The day nursery should 
have large windows, protected by blinds, and a southwestern 
exposure ; all other requisites, with the exception of beds, are 
the same as in the sleeping room. It is very convenient to 
have the two chambers adjoining, but capable of entire separa- 
tion by a door, so that one may be thoroughly aired without 
chilling the other. This arrangement, too, renders it practic- 



THE GENERAL MANAGEMENT OF CHILDREN. 83 

able, by standing the door open and raising the windows in 
the day nursery, to keep the dormitory cool in hot weather 
without exposing the child to currents of air. 

If an apartment has to be occupied during both the day 
and night, it must be vacated for half an hour or more in the 
evening and well aired before the child is put back to bed. 

The temperature of the rooms must be as uniform as pos- 
sible, the proper degree of heat being from 64 to 68° F. 

The crib should have high sides, to prevent the child from 
falling out and injuring himself, and should be provided with 
springs and a soft hair mattress, protected by a gum cloth, 
placed under a double sheet. The bedclothes must be light 
in weight, while varying in warmth according to the weather ; 
it is just as important to insist upon cleanliness here as in the 
clothing of the body. 

5. Exercise. 

A certain amount of muscular exercise is necessary for de- 
velopment and for the proper performance of the digestive 
functions. Infants, before they are able to stand, will use 
their muscles sufficiently if, when loosely clad, they are placed 
upon their backs on a bed and allowed to kick and turn about 
at pleasure. After the age of nine or ten months, a healthy 
child will begin to creep ; at the end of a year, he will make 
efforts at standing, and from four to eight months later will be 
able to walk by himself; children, however, present great 
differences in this respect, and a delay of a few months must 
not be considered as abnormal. So soon as efforts at creep- 
ing are made, there need be no fear that insufficient exercise 
will be taken ; the care should be rather to prevent over- 
fatigue. 

Fresh air and sunlight are as necessary as muscular exer- 
cise. The child must be taken out of doors every day, 
weather permitting, after arriving at the proper age ; this is 



84 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

four months for children born in the early fall and winter, and 
one month for those born in summer. 

In cool weather babies who are unable to walk should be 
taken out in a coach, or in the nurse's arms, for an hour 
in the morning and half an hour in the afternoon, while the 
sun is shining. In summer they may pass the greater part 
of the waking hours in the open air, provided they be well 
protected from the direct rays of the sun. 

Children old enough to walk may spend a longer time in 
the air in winter, and may be out all day in summer ; but 
until the fourth year, it is better to let them play about at will 
than take a long set walk. 

Until well advanced in childhood, the house is the safest 
place in damp and rainy weather, when there is a strong east 
or north wind blowing, and when the thermometer stands 
below i 5 . 

Management of Weak and Immature Infants. 

When premature expulsion of the foetus cannot be checked, 
children are born in a condition of feebleness requiring par- 
ticular care. Such children are under weight ; breathe and 
eat imperfectly ; have ill-formed organs and badly performed 
functions ; their skin is soft and delicate, bright red in color, 
and so transparent that the superficial blood-vessels can often 
be seen. Their cry is feeble, their muscles are inert and 
hardly seem to contract, and the movements of the limbs are 
rare and without vigor. Plunged in a sort of stupor, the infant 
has not even strength enough to suck, the muscles of the 
cheeks and of the tongue and palate being apparently too weak 
to perform this act, and deglutition itself is often slow — a 
grave symptom, since the regular accomplishment of this 
function alone renders life possible. 

The employment of artificial heat and a well-regulated 
alimentation are the methods of combating this condition. 



THE GENERAL MANAGEMENT OF CHILDREN. 



5 



Warmth and even temperature of the surrounding air are most 
important. The old method of accomplishing this was to en- 
velop the infant's body and limbs, under the ordinary clothing, 
with a layer of cotton wadding, and place a fold of the same 
around the head. Two or three bottles filled with hot water 
were placed under the blankets of the bed, and renewed from 
time to time as they became cold. An effort was made to 
maintain the temperature of the chamber at yy° F. All 
chancres of clothing; were made before a brisk fire, and two or 




t -.- 






. ' ' ' " : 




Fig. 4.— Tarnier's "Hatching-cradle." 



three times every day massage or friction, either dry or with 
various stimulating embrocations, was practised to strengthen 
the circulation. As an improvement upon this crude and very 
unsuccessful method, M. Tarnier has devised an apparatus 
called a " hatching-cradle," or incubator. 

It consists of a box made of wood, sixty-five centimetres 
long by fifty high and thirty-six wide, with sides twenty-five 
millimetres thick. The inside of the box is divided by a par- 
tial partition into two parts ; this partition, which is horizontal, 



86 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

is placed about fifteen centimetres from the bottom. The 
lower story is intended for hot- water bottles. Figure 4 shows 
the apparatus. 

There are two doors ; one is a sliding door on the lower 
side of the box, to push to either side, for the purpose of intro- 
ducing the hot-water bottles ; the other is at one of the ends 
(at T in the figure) ; it does not completely close the orifice, 
but allows a small amount of air to enter. The upper part, 
for the baby, contains the bedding, and is covered by a glass 
top at V ; it should close tightly and be held by two screws 
at BB. At A is an outlet for the air, to which a small venti- 
lator can be attached. In the opening between the two cham- 
bers a wet sponge is placed to keep the air slightly moist, and 
here also a thermometer is placed to mark the temperature. 
The heat is supplied by earthenware jugs at M ; they contain 
a pint of water each ; four or five are required to keep the 
temperature at the proper point — Sy° to 90 F. The chamber 
must be heated to this degree before the infant can be placed 
in it, and every one and a half or two hours one of the water 
bottles must be changed in order to maintain a constant tem- 
perature. The air passes in by the door, T, is heated by the 
bottles, and passing by the sponge, E, escapes at A ; the 
movement of the small ventilator in the latter position is the 
index that the air is circulating. The infant must be dressed 
in swaddling clothes, as it has been observed that the tem- 
perature is always two or three degrees higher under the 
clothing than in the chamber itself. Every hour or two, 
according to the case, the little patient should be taken out 
to receive food and have its napkins changed. The shorter 
the time occupied in these processes, the better. 

Auvard has suggested an improvement in Tarnier's incu- 
bator. In his apparatus a cylindrical reservoir of metal takes 
the place of the hot-water jars in the lower compartment of 
the couveuse. This reservoir is filled by means of a metallic 



THE GENERAL MANAGEMENT OF CHILDREN. 8? 

funnel at one end of the box and communicating with the 
cylinder through a metallic tube. The overflow of the cylinder 
is provided for by a curved metallic tube at the lower part of 
the cylinder, beneath the inlet through which the reservoir is 
filled. The air enters by a register on one side of the incu- 
bator instead of at the end, as in Tarnier's model. The 
other portions of the apparatus are the same as Tarnier's. 

The metallic cylinder is capable of holding ten litres of 
liquid (a little over ten quarts). To start the apparatus, about 
five litres of boiling water should be poured in, after which 
three litres may be poured in every hour. When ten litres 
are contained in the cylinder, the overflow-pipe carries off the 
excess. Auvard suggests having two vessels, capable of hold- 
ing three litres each, keeping one under the escape-pipe and 
the other over the fire, reheating the water in the vessel filled 
by the escape -pipe and having it in readiness for the next 
changes. The two vessels may thus be used alternately, and 
but little time consumed in the heating of the apparatus as 
compared with that required in the use of Tarnier's invention. 

To empty the cylinder, a rubber tube is attached to the 
escape-pipe, by which it is made to act as a siphon — a small 
quantity of water poured into the cylinder through the funnel 
being sufficient to start the liquid. 

The length of time the child remains in an incubator will 
vary from fifteen days to three weeks, a month, or even more. 
It should not be removed permanently until it has acquired 
sufficient vigor to live in the ordinary atmosphere of the apart- 
ment. To accustom the child to this atmosphere, it should, 
as it grows stronger, be removed from the incubator for an 
hour at a time during the warmest part of the day. 

It is best to continue the use of the apparatus at night for 
some time after the child becomes accustomed by day to 
ordinary surroundings, for the danger of chilling from changes 
in the atmosphere is greater at night. 



88 



DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 



Auvard recommends the use of the incubator in all cases 
where the vitality of the child is enfeebled either by external 
causes, as cold, or internal causes, as premature birth, con- 
genital feebleness, cyanosis, wasting, or other general maladies 
enfeebling to the newborn. 

The excellent result's obtained by the employment of incu- 
bators is shown by the following statistics, obtained from the 
Maternite, in Paris : 



Weight of Child. 


No. of Infants. 


No. that Lived. 


No. that Died. 


1000-1500 grammes. 
1501-2000 " 
2001-2500 " 


40 
131 

112 


12 

96 
IOI 


28, or 70 per cent. 

35, or 26.7 

II, or 9.8 " 



Before the introduction of the incubator, infants died at the 
rate of 66 per cent.; since, the average proportion is 36.6 per 
cent. The apparatus has also been used with success in the 
treatment of sclerema, oedema, and cyanosis attacking the 
newly born. 

From the very first day an attempt must be made to put 
these feeble infants to the breast ; and if they be too weak to 
suck, the milk may be squeezed into the mouth, or first into 
a warm spoon and then given to the child. The mother's or 
nurse's milk, without dilution or addition, is the best food, 
though if this cannot be obtained modified cows' milk must 
be used. In these cases laboratory milk is very useful ; the 
formula varies with the size and strength of the infant, but may 
be constructed from the following prescription : 

Fat, 1 to 1.5 per cent. ; sugar, 3 to 4. 5 percent. ; albumin- 
oids, 0.2 to 0.75 percent.; alkalinity, 5 percent.; heat at 1 5 5 ° F. 

When the infant is very small, six to eight grammes (f5ij) 
are enough for a meal ; larger babies require from ten to fifteen 
grammes (f5iiss-f5iiiss). There should be at least twelve 
meals every twenty-four hours. 



THE GENERAL MANAGEMENT OF CHILDREN. 89 

Gavage. — It often happens that the babe will drink badly 
and throw up half the liquid given. Under this deficient 
feeding the little sufferer gets rapidly worse, loses weight, and 
frequently has diarrhoea. In these cases " gavage " should 
be resorted to. The apparatus is quite simple, being nothing 
more than a urethral catheter of red rubber (Nos. 14-16 
French), at the open end of which a small glass funnel is ad- 
justed. The infant should be placed upon its back on the 
knee, with its head slightly raised ; the catheter, being wetted, 
is introduced as far as the base of the tongue, whence, by the 
instinctive efforts at deglutition, it is carried as far down as 
the oesophagus and into the stomach. The liquid food is 
next poured into the funnel, and by its weight soon finds its 
way into the stomach. After a few seconds the catheter 
must be removed, and here is the great point in the opera- 
tion : it must be removed with a rapid motion and at once, for 
if it be withdrawn slowly, all the food introduced will be 
vomited ; at the same time the upper end of the tube must 
be tightly pinched to prevent any remaining fluid dropping 
into the pharynx, and after its removal the jaws should be 
held open for a short time to prevent gagging. The stomach 
should be washed (lavage) before the first feeding, and subse- 
quently once each day to remove mucus and undigested food 
if any chance to be present. 

The number and quantity of meals thus given must vary 
with the age and strength of the infant. The quantity varies 
from foij to f§ss, but the interval must be longer than in 
ordinary feeding, three instead of two hours. Mother's milk 
is the best for gavage, but properly modified milk mixtures 
may be used if it be impossible to obtain it. 

Should the gavage be too copious, the infant gains rapidly 
in weight and size. This increase, however, is due to oedema, 
and quickly disappears when a proper quantity of food is 
administered. When excessive feeding is continued, indiges- 



90 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

tion soon sets in, and the patient dies of gastritis or enteritis. 
As soon as the child gains strength this mode of feeding may 
be alternated with nursing or bottle-feeding, and gradually 
the breast or the bottle may be entirely substituted for it. 
Nevertheless, the least digestive disturbance indicates the 
necessity of a return to gavage. 

Even when the child is old enough to nurse or take a 
bottle, should it be weak, it is useful, besides the regular 
feedings, to resort to gavage three or four times a day. This 
M. Tarnier calls gavage de reufort, as it keeps up the strength 
of the infant so that it can take food and digest well. 

The absence of the sensation of hunger and of the neces- 
sary strength to suck are not contraindications to this mode 
of feeding ; and by it, together with the use of incubators, 
the actual period of vitality has approached the legal period, 
which in French law is six months of intra-uterine life. 

Lavage. — Of late years stomach washing has been prac- 
tised in nursing children with good results. The apparatus 
employed consists of an elastic tube joined to a small glass 
tube, to the other extremity of which another piece of elastic 
tubing with a wide opening is adapted. Lavage may be 
practised a few days after birth without the least danger to 
the infant. The instrument is inserted while the child is in 
a sitting position, the trunk and arms being enveloped in 
napkins and protected by a rubber cloth. The child's mouth 
is opened by exerting slight pressure upon the chin, while 
the larynx is slightly pressed inward by the index finger of 
the right hand. The tube having been previously dipped 
in warm water is held as a pen, and the smaller extremity 
slowly introduced, advancing by the simple, repeated act of 
deglutition. The contact of the tube with the stomach causes 
contraction of the walls, thereby expelling a quantity of liquid 
through the tube, the broad end of which is depressed some- 
what until the stomach is empty. The best fluid for lavage 



THE GENERAL MANAGEMENT OF CHILDREN. 9 1 

is sterile normal salt solution (one drachm of table salt to the 
pint), at a temperature of ioo° F. for ordinary conditions, 
but increased to iio° F. if there be great gastric irritation ; 
the quantity to be introduced into the stomach at one time 
should not exceed the normal gastric capacity. The funnel- 
shaped end of the tube is raised to pour in the water and 
lowered to expel it. The washing may be repeated two, 
three, or more times in succession until the liquid returns 
quite clear. 

In addition to its use in gavage, lavage is indicated : (i) In 
cases of repeated vomiting ; (2) in cases where there is an 
affection of the mouth which is capable of extending to the 
stomach ; (3) in cases of eclampsia caused by indigestible 
substances ; (4) in cases of poisoning. 

After the lavage the child should remain perfectly quiet for 
fifteen or twenty minutes before being fed. 



0,2 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 



II. Massage in Pediatrics. 



Systematic manipulation is of great value both as a means 
of preserving health and as a scientific method of treating 
certain diseases in children. 

Mere rubbing or friction of the surface cannot be included 
under massage in its literal sense, still it is a useful form of 
manipulation, and needs no special instruction, being possible 
to any intelligent, soft-handed mother or nurse. 

Massage, on the contrary, is an art, and like every other 
art requires study and patient preparation for its successful 
practice. It is a powerful remedy, too, and, like other agents 
of its class, as potent for evil as for good in unskilled hands. 
Therefore, to insure good results, a trained masseuse is 
necessary — and she must act under the direction of the 
physician. 

Massage includes several processes of manipulation. Those 
given by Murrell, from whose excellent little work * I have 
taken much of the description of the different " movements," 
are effleurage, petrissage, friction, and tapotement. 

Effleurage is a stroking movement made with the palm of 
the hand passing with more or less force over the surface of 
the body centripetally. The movements are made to follow 
as nearly as possible the direction of the muscle fibres, and 
for deep-seated tissues the knuckles can be used instead of the 
palm. This method is of minor value in itself, but of great 
use when combined, as is the rule, with the procedures to be 
described. 

Petrissage consists essentially in picking up a portion of 

* " Massage as a Mode of Treatment." W. Murrell. 



MASSAGE IN PEDIATRICS. 93 

muscle or other tissue with both hands, or the fingers of one 
hand, and subjecting it to firm pressure, at the same time 
rolling it between the fingers and subjacent tissues. The 
hands must move simultaneously and in opposite directions, 
the skin must move with the hands to avoid giving pain, and 
the thumb and fingers must be kept wide apart in order to 
grasp a bulk of tissue, a whole muscle belly, for instance. The 
manipulation must be uniform, in a direction from the extrem- 
ities toward the centre of the body, bearing in mind the 
arrangement of groups of superficial muscles and keeping 
well in the interstitia. 

Friction, or massage a frictions, is performed with the tips 
of the fingers. It is a pressure movement rather than a rub- 
bing. It is always associated with effleurage, and, to be of 
any use, must be performed quickly and readily. 

Tapotement is a percussion, which may be made with the 
tips of the fingers, their palmar surfaces, the palm of the 
hand, the back of the half-closed hand, the ulnar or radial 
border of the hand, or with the hand flexed so as to contain, 
when brought in contact with the surface of the body, a 
cushion of air. 

The hand of the masseuse must be perfectly clean and 
soft, and the fingernails short and smooth. The length and 
frequency of the sittings must vary with the individual case. 
Murrell is in favor of short and frequent seances, and also 
recommends dry massage — that is, without the use of oil, 
liniments, or ointments ; vaseline especially is to be avoided. 

Our knowledge of the physiological action of massage is 
based upon experimental research and clinical experience. 
Experiments were made by Dr. Gopadze (quoted by Murrell) 
upon four medical students, who were kept in hospital and 
subjected to systematic manipulations for twenty minutes or 
more daily. The seance began with effleurage, followed by 
petrissage, friction, and tapotement, and ending with a second 



94 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

effleurage. The results were increased appetite and a notable 
gain in body-weight. The axillary temperature fell, never 
more than 0.5 , for about thirty minutes after each massage ; 
then it rose steadily, and an hour later was generally a degree 
higher than at the commencement of the operation. The 
respiratory movements were uniformly increased in frequency, 
depth, and fulness. The pulse varied with the kind of 
"movement " used — light surface effleurage increased its fre- 
quency, while petrissage made it slower. 

Zabludowski, experimenting on himself and two servants 
for eighteen days, noted increased bodily and mental vigor 
and improved appetite and sleep. 

Clinical experience shows that massage increases the ac- 
tivity of the circulation, reddens the skin, and elevates the 
temperature in the part manipulated. It also increases the 
electrical contractility of muscular tissue, and stimulates the 
flow of lymph in the lymphatic vessels. Muscular stiffness 
and fatigue are relieved, nervous irritability is calmed, and 
restless and wakeful patients are soothed by it into refreshing 
sleep. 

With these facts at hand, it is not difficult to see what a 
useful therapeutic agency we possess in skilfully employed 
massage. By its application we have the power to prevent 
the atrophy of muscles and to augment muscle tone ; to build 
up such tissues as fat and blood ; to improve nerve tone, both 
directly, by producing a better blood supply, and indirectly, by 
relieving and giving rest and sleep ; and, finally, to hasten 
the absorption of waste tissue and of morbid effusions. At 
the same time it must always be remembered that massage is 
a powerful remedy. A short seance with gentle movements 
may do good in infantile palsy, for example, but it does not 
follow that by doubling the time or force twice as much 
benefit will be derived. In fact, the reverse of the proposi- 
tion is true ; short, gentle massage maintains the size and 



MASSAGE IN PEDIATRICS. 95 

tone of the muscles, while long; forcible manipulation causes 
them to atrophy quickly. The same truth runs through the 
whole question and must be observed. 

Before entering upon the therapeutic application of mas- 
sage proper, it will be well to revert to the process of simple 
rubbing, already mentioned. This is of much value as a gen- 
eral hygienic measure. Each day, after the bath, the skin 
having been thoroughly dried by a soft, warm towel, the 
whole surface should be gently rubbed with the palm of the 
hand, the process occupying from five to ten minutes. This 
increases the capillary circulation, encourages thorough re- 
action, aids nutrition, and adds vigor to the frame. Weakly 
children especially thrive under it. In older children friction 
with a soft towel may be substituted for hand-rubbing, but 
this change should not be made before the fifth or sixth 
year. 

Sometimes it is well to rub certain portions of the body 
more thoroughly than others. Thus, in rickets the spine 
should receive especial attention ; in indigestion and constipa- 
tion, the abdomen ; in weak ankles, the feet and legs, etc. ; 
though even in these cases the general surface must receive a 
share. 

Massage may be employed with advantage in the following 
diseases of childhood : 

(a) Chronic gastro-intestinal catarrh. In this condition the 
skin is harsh, and often so dry that a shower of epidermic 
scales falls on the removal of the underclothing ; the muscle 
tone is faulty, general nutrition is impaired, and there is a 
determination of blood from the surface toward the mucous 
membranes. To get the skin active, and in this way balance 
the circulation, is an important step in the reestablishment of 
normal digestion, secretion, and excretion, the essentials of 
perfect nutrition. To accomplish this, a full, warm bath is 
administered every evening, just before bedtime, the patient 



g6 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

remaining in the water for five minutes. Then the surface is 
thoroughly dried and warm olive oil is gently rubbed into the 
skin for fifteen minutes, the child enveloped in a light blanket 
and put to bed. After a little time diaphoresis begins. So 
soon as the sweating is free, the skin is again dried and the 
night-dress put on in preparation for sleep. Next morning, 
at some convenient time after breakfast, the child is subjected 
to twenty minutes' massage (petrissage with effleurage). 
The inunctions are continued until the skin becomes soft and 
active, and massage is employed daily until there is a decided 
improvement in the amount of flesh and general strength, a 
period generally of two or three weeks. Afterward " move- 
ments " every third day will be sufficient to complete the 
cure. 

In these cases massage not only aids the baths and inunc- 
tions in their general action, but directly and powerfully 
increases nutrition and muscle tone, and materially hastens an 
otherwise slow process of recovery. 

(fi) Constipation. Manipulation is a very efficient remedy 
in habitual constipation, and there are many cases that can be 
cured by it, combined with a properly regulated diet, without 
the use of drugs. Petrissage of the colon is the best method, 
instructions being given to follow the natural course of the 
faeces through this portion of the gut ; thus, beginning in the 
right iliac region, to proceed upward to the right hypochon- 
drium, to cross over to the left hypochondrium, and then 
downward to the left iliac region. In this way the ascending, 
transverse and descending colon are manipulated in order. 

Five or ten minutes every morning, or every morning and 
evening in obstinate cases, constitute the proper duration and 
frequency of the applications. The pressure must be gentle, 
as delicate tissues are being dealt with. 

In this condition I have not found the dry method so 
efficient as the combination of massage with the inunction of 



MASSAGE IN PEDIATRICS. 97 

warm olive oil or a weak ammonia liniment. The addition of 
aloes to the liniment, a plan recommended by some authors, 
has never been necessary in my experience. 

Sometimes tapotement with the flat hand, with the hand 
partly closed, forming a cushion, or with the margin of the 
hand, is necessary, but the course of the colon must always 
be followed. The therapeutic action of this mode of treat- 
ment is, undoubtedly, threefold : it increases the intestinal 
and other secretions ; it increases the peristaltic action of the 
intestinal fibres ; and it mechanically forces accumulated faecal 
matter toward the rectum. 

(V) Colic. Every experienced mother knows how often 
flatus, the cause of colicky pain, is expelled from the stomach 
or intestines by gently rubbing the abdomen with the hand. 
Any approach to scientific manipulation is much more efficient, 
and two or three minutes' effleurage may be resorted to, as 
the urgency of the symptoms requires, with the most satis- 
factory effect. In this connection it must be remembered, 
also, that rubbing of the feet to increase the circulation is an 
important aid in relieving colic. 

(d) General debility and anaemia. These conditions are much 
benefited by short, frequently repeated courses of massage. 
In the convalescence from many diseases, both acute and 
chronic, in which these states exist, manipulation improves 
general nutrition, and strength is rapidly gained. 

(e) Infantile paralysis. Here massage of the paralyzed 
muscles brings more blood into them and maintains their 
nutrition until, in favorable cases, new cells in the cord take 
on the function of those which have been destroyed. 

In essential paralysis the affected members are always cold, 
and the muscles contract feebly, if at all, under the influence 
of electricity. By systematic massage — petrissage combined 
with effleurage, and both performed centripetally — an im- 
provement takes place with more or less rapidity. The first 



9© DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

indication of this is an increase in the temperature of the parts, 
continuing for several hours after the rubbing. Then the 
electrical contractility of the muscles begins to return, and 
they respond to a current that at the commencement is 
entirely inoperative. 

In recent cases the sittings should be of short duration and 
frequently repeated — five or ten minutes, three or four times 
daily. As improvement advances, the frequency may be 
reduced, and in chronic cases twice a day will be sufficient at 
any time. 

Electricity is of great aid in the treatment, but it does not 
take the place of massage, for while it causes contraction and 
congestion of the muscles and hyperemia of the skin, it does 
not have the same power of arresting rapid wasting. The 
constant current is to be employed. In the beginning the 
current must be mild, so as not to produce pain or emotional 
excitement, and often it is well to apply the sponges without 
current for several sittings, to accustom the little patient to 
the novelty of the procedure without producing any sensation. 
The treatment may be begun about three weeks after the 
onset of the paralysis, earlier applications being attended by 
the risk of increasing spinal congestion. 

Well wetted, large sponges should be used. The positive 
pole is kept stationary and placed close to the sacrum or 
lower part of the back when the legs are to be galvanized, 
or to the back of the neck in case the arms are the affected 
members. The negative pole is slowly moved up and down 
over the surface of the paralyzed limb, thus making and break- 
ing the circuit gradually and without pain. The muscles that 
do not contract to faradism are the ones to be influenced by 
galvanism ; in other parts hyperemia of the muscles and skin 
only is required. 

Three or four electrical sittings a week are sufficient. They 
should be short at first, ten to fifteen minutes, and gradually 



MASSAGE IN PEDIATRICS. 99 

increased in duration and force as tone and contractility return, 
care being taken never to overfatigue the muscles. 

(/) Chorea. So far as this branch of the management of 
chorea is concerned, it requires to be aided by proper diet and 
rest in bed. On the onset of an acute attack the patient is 
put to bed, given a full supply of good food, and allowed to 
rest for two days without massage. Should the choreic 
movements be very violent, the sides of the bed are padded to 
prevent the child bruising himself, or, if too violent for this, 
to give security, he is slung in a hammock. 

At the end of this time the regular treatment is initiated. 
The plan, a slight modification of that recommended by Good- 
hart, is as follows : 

The child — at seven years of age, for example — has at 5.30 
A. m., a breakfast-cupful (fSviij) of warm milk ; 7 a. m., a break- 
fast-cupful (fSviij) of warm milk, three slices (1 oz. each) of 
bread, buttered ; 9 a. m., 2 to 4 tablespoonfuls (fSj-ij) of a 
good liquid extract of malt; 10 a.m., massage for fifteen 
minutes, after which a teacupful (foyj) of warm milk ; 12.30 
p. m., dinner of well-cooked fresh vegetables, bread, a break- 
fast-cupful (fSviij) of milk, with rice or other light pudding; 
4.15 p. m., same as 7 a. m., with a soft-boiled egg; 7 p.m., 
extract of malt, as at 9 a. m. ; 7.30 p. m., massage, fol- 
lowed by a teacupful (f§vj) of warm milk. At the end often 
days or a fortnight, increase the amount of bread to four slices, 
add a lamb chop or a bit of chicken at dinner (12.30 p. m.), and 
increase portions of milk so that an extra pint is taken through 
the day. Time of massage is also to be extended to thirty 
minutes. 

After two or three weeks the patient may be allowed to sit 
up in bed, well supported by pillows, and may have a kw 
toys to play with. It is a golden rule, however, never to 
hurry a patient with chorea out of bed. The muscular 
strength is more quickly recovered while at perfect rest, and 
LofC. 



IOO DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

too early exertion often causes a relapse. While carrying out 
this plan Goodhart employs no medicines, but in my experience 
recovery has been more rapid under the conjoint use of Fow- 
ler's solution, administered in daily increasing doses. 

(g) Other nervous diseases in which massage is employed 
with success are pseudo-hypertrophic paralysis ; facial paral- 
ysis ; neurasthenia and spinal irritability occurring in girls 
about the approach of puberty. 

(/i) Pleuritic effusions (serous) ; fibroid pleurisy ; enlarged 
lymphatic glands ; stiffened rheumatic joints, and that ill- 
defined rheumatic condition so pften encountered in young 
subjects, and known as " growing pains," are all benefited by 
rubbing. In these special instances the manipulations are 
generally combined with the use of embrocations, though the 
curative effects cannot be attributed to the latter alone. 

In concluding the subject of massage in childhood, it is a 
point of importance to mention that those cases in which the 
manipulation is immediately followed by a sensation of comfort 
or by a refreshing sleep are most benefited by it. On the 
contrary, those cases that are rendered wakeful and irritable 
derive little benefit, and perhaps positive injury, from rub- 
bing. This I have especially noted in cases of general debility 
and anaemia, and my own experience has been confirmed by 
practical observers in whose judgment one. must have con- 
fidence. 



PART I. 

DISEASES PRODUCED BY IMPROPER 
FOOD AND IMPERFECT NUTRITION. 



CHAPTER I. 
SIMPLE ATROPHY. 

Simple atrophy, or the slow wasting commonly termed 
"marasmus," is a familiar occurrence in hand-fed babies, and 
one of the most frequent causes of death in early infancy. It 
is a condition in which there is extreme wasting of the soft 
tissues of the body, either without special organic lesions or 
with catarrhal inflammation of the mucous membrane of the 
gastro-intestinal canal. 

Etiology. — Wasting usually occurs during the first twelve 
months of life, though it may begin in the second year, and is 
most frequently encountered among children of the poor. It 
arises both in breast-fed babies and in those brought up by 
hand, being in either case due to insufficient nourishment. 
The child wastes because he is starved. 

Food can be insufficient in two ways : first, when it is sup- 
plied in amounts too limited to meet the demands of the 
system ; and, second, when it contains a minimum of the 
elements essential to nutrition or presents them in a form ill 
adapted to the feeble digestive powers of infancy. For ex- 
ample, nursing infants waste in consequence of feeding either 
from a breast that yields too little good milk, or from one that 
secretes abundantly a poor, watery fluid entirely unfit for 



I02 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

nourishment. With artificially fed children, on the other 
hand, it rarely happens that the quantity of food is too small ; 
the fault lies, rather, in the direction of quality. Undiluted 
cows' milk, milk thickened with starchy materials, farinaceous 
foods, and even table food — meat, vegetables, and bread — are 
given to babies a few weeks or months old. Now, all these 
are highly nutritious, but the digestive apparatus is not suf- 
ficiently developed to prepare them for absorption. They are 
strong foods, adapted to nourish and strengthen much older 
children and adults ; but as the infant cannot assimilate them, 
he starves no less surely, if more slowly, than when taking no 
food at all. Such aliment, also, while remaining undigested 
in the stomach and intestines, undergoes fermentation, with 
the formation of irritant products, causing vomiting or diar- 
rhoea — conditions that still further lower the vital powers and 
hasten atrophy. 

It is often possible to trace the disease directly to want of 
cleanliness in the feeding apparatus, and especially to the use 
of a form of bottle that has until lately been very popular in 
this country. This bottle has, in place of a plain gum tip, an 
arrangement of glass and rubber tubing of small calibre. One 
extremity of the rubber tubing, which is eight or nine inches 
long, terminates in a small nipple-shaped tip and bone shield ; 
the other, often penetrating an ornamental rubber cork, is fitted 
to a bit of glass tubing long enough to extend quite to the 
bottom of the bottle. By this plan the trouble of holding the 
bottle and keeping it at a proper angle during feeding is avoided. 
This seeming advantage, though, is counterbalanced both by 
the minor drawback that the child, left to itself, is apt to con- 
tinue suction long after the bottle is exhausted, thus swallow- 
ing a quantity of air, and by the greater disadvantage that the 
tubing can never be kept clean. 

For a number of years the author made it a rule to ask for 
the bottle of every hand-fed infant presented for treatment, and 



SIMPLE ATROPHY. IO3 

few days passed without his seeing several of the complicated 
contrivances referred to. In almost every instance, notwith- 
standing the most careful and frequent cleansing, a sour odor 
could be detected ; and if milk were present, it contained 
numerous small curds ; while in cases of carelessness the odor 
was intolerable, and the interior of the tubing was incrusted 
with a layer of altered curd. With simple bottles and tips, on 
the contrary, alterations in the character of the milk and coat- 
ing of the interior of the tips were very infrequent. As there 
is little difficulty in keeping the bottles themselves clean, there 
can be only one reason for this difference : namely, in the 
simple instrument the nipple is readily removed and as easily 
inverted and cleaned, but in the other there is no way of clean- 
ing thoroughly the twelve or more inches of fine tubing. The 
latter cannot be inverted, and the passage of a stream of water 
or of a stiff brush only imperfectly removes the milk clinging 
to the interior. This, of course, soon undergoes decompo- 
sition, and in this state quickly inaugurates change in the next 
supply of milk placed in the bottle. It is evident that a con- 
stant supply of food, no matter how good originally, thus 
rendered acid and partially curdled, and contaminated by bac- 
teria, must, like an excess of farinaceous or other unsuitable 
food, produce irritation of the alimentary canal, interfere with 
the process of nutrition, and lead to a state in which the fea- 
tures of wasting and disordered digestion are combined. 

The custom of preparing in the morning, without Pasteur- 
ization, a supply of food sufficient for the whole day is another 
fruitful cause of atrophy. If this be done, no matter how 
carefully the mixture be proportioned or how well adapted to 
the age and digestion of the child, it becomes unfit for con- 
sumption after standing eight or ten hours. The change may 
or may not be appreciable to the senses, but test-paper will 
always show acidity and the microscope demonstrate the ex- 
istence of actively moving bacteria. 



104 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Again, food upon which a child has thriven for three or four 
months, perhaps, can become unsuitable, and consequently 
lead to wasting, if the digestive powers be suddenly reduced 
by an intercurrent disease. 

Wasting, while it is less serious in babies suckled at the 
breast, frequently occurs in a modified form under these cir- 
cumstances. For this there are several causal factors. Thus, 
an infant may be given to a wet-nurse whose own baby is much 
older than her foster-child. In this case the milk is usually 
unsuitable, and the nursling, unable to digest and assimilate 
it, ceases to thrive, and may suffer from indigestion or diar- 
rhcea. Human milk is also affected by dietetic and emotional 
influences, and, altering with the state of the general health 
of the mother, miy deteriorate in quality or otherwise become 
unfit for food. Finally, it happens at times that, although the 
mother may be healthy and have an abundant breast, and 
although the infant may be robust, yet it does not thrive on 
the milk supplied. Here the fault is generally an overrich- 
ness in either casein or fats. While noting these facts, it must 
be remembered that in many cases of wasting in nursing infants 
the fault is not with the mother's milk, but with the child, an 
attack of catarrh having temporarily impaired the process of 
digestion. Without care and proper management this de- 
rangement may be prolonged, and not infrequently leads to 
unnecessary weaning. 

Morbid Anatomy. — After death the muscular and other 
tissues are found in a state of atrophy, and there is a total dis- 
appearance of normal fat from the body. Fatty degeneration 
of the kidneys, lungs, and brain may be discovered ; the 
stomach is sometimes ulcerated, and hemorrhagic effusions 
into the cranium are not uncommon. 

Symptoms. — The clinical features differ materially accord- 
ing to whether the element of insufficiency be one of quantity 
or quality. They may, therefore, be divided into two classes : 



PLATE 1, 




Simple Atrophy. Age. Three Months. 
Weight at birth, 4 pounds ; weight at three months. 3*2 pounds. Fed on a mixture of cane- 
sugar and water. 



SIMPLE ATROPHY. IO5 

viz., those developed by food that is suitable, but not sufficient, 
and those resulting from unsuitable food. 

The first group of symptoms is most frequently encountered 
in children who have been nursed at the breasts of feeble or 
overworked mothers, in whom the milk is often both scanty 
and of poor quality. There is a gradual loss of plumpness, 
the muscles grow flaccid, and there seems to be an arrest of 
growth. The face is white, the lips pale and thin, the skin 
harsh and dry or too moist, and the anterior fontanelle level 
or slightly depressed. The temper is irritable and sleep rest- 
less and disturbed ; or the child is abnormally quiet, dozing 
constantly, and sucking his fingers until they become raw. 
When nursed, the child will seize the nipple ravenously ; then, 
if there be little milk, he quickly drops it to cry passionately, 
as if disappointed at not being able to satisfy his hunger ; but 
if the milk be abundant, though poor, he will lie a long time 
quietly at the breast, and often fall asleep with the nipple in 
his mouth. The bowels are inclined to constipation, the stools 
being scanty, hard, and dry. Physical signs connected with 
the chest and abdomen are negative, and no indication of 
disease of any special organ of the body can be detected. 

In the second class, features of wasting are associated with 
those of irritation of the alimentary canal, and the symptoms 
altogether are much more grave than in cases of the pre- 
ceding group. The subjects are almost invariably hand-fed 
infants. Emaciation progresses with a rapidity and to an 
extent depending upon the original strength of the child's 
constitution, the age at which artificial feeding was begun, and 
the sort of food employed. It is often so extreme that an 
infant several months old weighs less and appears smaller 
than at birth, and this even after a large quantity of food, such 
as it is, has been consumed. The combination of great wast- 
ing with a voracious appetite is very striking, and is only 
apparently contradictory, since hunger — the demand of the 
9 



106 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

tissues for reparative material — cannot be appeased by food 
which, from its bad quality, is incapable of digestion or 
proper preparation for absorption and assimilation. Unsuit- 
able food, too, by irritating the mucous membrane of the 
stomach, creates a fictitious appetite. 

Sooner or later the face becomes pinched, the eyes sunken ; 
the lips are pale, and when moved display a deep furrow about 
the angles of the mouth ; the facial expression is uneasy or 
languid, and the anterior fontanelle is deeply depressed. The 
skin, generally, is dry, harsh, and yellowish, hangs in loose 
folds over the bones, and may be mottled by an eruption of 
strophulus or urticaria, or present red patches of intertrigo in 
the neighborhood of the genitalia and over the buttocks and 
inner surface of the thighs. The extremities are cold and the 
hands claw-like. The tongue is heavily furred or red and 
dry, and, with the mucous membrane of the mouth, may be 
the seat of aphthous ulceration or thrush deposit. As already 
stated, the appetite is often ravenous, and the cries of hunger 
are violent, oft repeated, and only temporarily silenced by 
food ; thirst is increased ; colic is common ; the bowels are 
constipated, and the stools, which are voided with difficulty 
and straining, are composed of a few light-colored, cheesy 
lumps partly covered with greenish mucus. 

Attacks of acute vomiting and diarrhoea often interrupt the 
regular course of the disease. At such times there is 
moderate fever during the night, though ordinarily the tem- 
perature is subnormal. Again, chronic vomiting and chronic 
diarrhoea are apt to arise as complications, and greatly increase 
the danger of a fatal termination. 

Sleep is restless and disturbed, and many hours, particu- 
larly during the night, are spent in fretful crying. A common 
group of symptoms connected with the nervous system is 
a partial convulsive seizure, termed by the laity " inward 
spasms." When these occur, the upper lip becomes livid, 



SIMPLE ATROPHY. IO7 

somewhat everted, and tremulous ; the eyeballs rotate or 
there is a slight squint, and the ringers and toes are strongly 
flexed. They frequently usher in true convulsions. 

Sometimes the nervous manifestations are much more 
complex. Thus, I have seen cases where there was retrac- 
tion of the head, boring of the head into the pillow, an 
approximation to the "gun-hammer" decubitus, general 
hyperesthesia, and the tache cerebrale — all suggestive of 
tuberculous meningitis. Such symptoms — spurious hydro- 
cephalus — disappear under an appropriate diet with proper 
medicinal treatment, and are to be referred to an intensely 
excitable nervous system — a condition depending upon in- 
sufficient nourishment, and differing; merely in degree from 
that leading to the partial convulsions. 

There is, of course, extreme prostration, the cardiac action 
is weak, and the respiration shallow. The urine is citron- 
colored or very dark yellow, has a specific gravity of 1.009 to 
1.0125, a strong, characteristic odor, and is diminished in 
quantity. It is always cloudy or milky, becoming clear only 
on the approach of recovery. The sediment deposited on 
standing contains certain variously shaped cylinders, fatty 
elements with tinted nuclei, mucus, colored uric acid, urates 
in a crystallized or amorphous condition, pigment, etc. The 
reaction is sometimes highly acid. The proportion of urates 
is decidedly, that of uric acid notably, and of coloring-matter 
and extractives somewhat, increased. Albumin is always 
present in variable quantity, and sugar also may be frequently 
detected. 

Death may be preceded by convulsions or the symptoms 
of spurious hydrocephalus, or may result from prostration. 

Diagnosis. — Great emaciation may result from inherited 
syphilis or acute tuberculosis, but both these conditions are 
attended by characteristic symptoms, rendering their diag- 
nosis a matter of little difficulty. In inherited syphilis the 



I08 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

child snuffles and cries hoarsely. The skin is dry, wrinkled, 
old-parchment-colored, and mottled with coppery or rust- 
colored spots. Often the buttocks, perineum, genitalia, and 
upper portion of the thighs are the color of the lean of ham. 
Mucous patches are present at the margins of the anus and of 
the lips. The corners of the mouth are fissured, the nostrils 
red and excoriated, and the bridge of the nose is flattened. 
Enlargement of the spleen can frequently be detected on 
abdominal palpation. 

In acute tuberculosis there is fever, the rectal temperature 
reaching ioo° to ioi° F. in the evening; cough with irreg- 
ularly distributed rales, and usually slight cedema of the legs. 

When symptoms resembling those of tuberculous meningitis 
are present, it is often necessary to delay a definite opinion. 
In simple atrophy, however, the open fontanelle is level or 
depressed ; the belly is never scaphoid ; the bowels, though 
frequently constipated, are never locked ; vomiting is apt to 
be associated with diarrhoea ; the respiration and pulse are 
regular in rhythm ; the temperature, as a rule, is subnormal ; 
there is no hydrencephalic cry ; and the antecedent history 
and the course are different from the tuberculous disease. 

Prognosis. — A vast number of cases die annually in our 
large cities, yet the results of appropriate management are 
often rapidly and surprisingly successful. Patients should 
never be given up unless there be extreme wasting and pros- 
tration, or unless the symptoms of spurious hydrocephalus 
arise, convulsions occur, or obstinate chronic vomiting or diar- 
rhoea be developed. 

Treatment. — For the arrest of wasting from insufficient 
nourishment, the first and main thing to be attended to is the 
diet. Without entering at length into this subject,* it may 
be stated, as a uniform rule, that in selecting a diet the object 

* For the details of diet and general management, see Introduction. 



SIMPLE ATROPHY. IO9 

should be to fix upon one suited to the age and digestive 
powers of the child, so that he may be able to digest, and, 
therefore, be nourished by, all the food consumed. 

Generally, infants under twelve months who have to be 
either partially or entirely "brought up by hand" do well 
upon cows' milk, diluted with lime water or with barley water. 
Often it is well to Pasteurize the milk, or — a method which 
has been most uniformly successful in my hands — to add to 
the milk mixture peptogenic milk powder, and predigest at a 
temperature of 1 15 F. for six minutes. The food should be 
administered from a bottle capable of holding half a pint, made 
of colorless glass, so that the least particle of dirt can be seen, 
and provided with a soft india-rubber tip. Unless Pasteurized, 
the whole quantity of food intended to be given in a day should 
never be prepared at once, but each portion must be made 
separately at the time of administration. Thus, a bottle of the 
sort described, absolutely clean, may be filled with a mixture 
of one part of lime water to two or three of sound milk, or 
with one part of barley water to two or three of milk, to either 
of which may be added from one to two tablespoonfuls of 
cream and a teaspoonful of pure sugar of milk. The bottle 
must next be placed in hot water until the contents become 
warm, when it is ready for the child. 

The degree of dilution of the milk and the proportion of 
cream added vary with the age and the feebleness of digestion, 
but it is upon the latter that we must chiefly base the com- 
position of the food. Lime water is the preferable diluent 
when there is frequent vomiting or acid eructation. Both it 
and barley water are of service in preventing the formation of 
large, compact curds — an object that is even better accom- 
plished by peptogenic milk powder, and by the process of 
partial predigestion. In some cases it may be necessary to 
discontinue milk foods entirely, putting the child temporarily 
upon weak broths or raw-beef juice. 



IIO DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

After digestion has been brought into good condition, the 
food may be cautiously increased to a standard suitable for a 
healthy child of the same age. 

Once daily the patient should be bathed in warm water, 
or at least sponged over with warm water, and every 
morning and evening warm olive oil or cod-liver oil should 
be rubbed, for five to ten minutes, into the skin over the 
abdomen and chest. At the same time the belly must be 
completely covered with a soft flannel binder, and the feet and 
surface generally kept warm by woolen clothing. In this way 
attacks of colic, if not entirely prevented, are rendered much 
less frequent and severe. 

If there be intertrigo, cleanliness and the free use of oxide- 
of-zinc ointment usually suffice to effect a cure. 

Of medicines, bicarbonate of sodium, pepsin, pancreatin, nux 
vomica, and cod-liver oil are perhaps the most useful. Cod-liver 
oil should not be given until the digestive powers have been 
brought into a comparatively normal state by^ proper food, 
antacids, and digestants, and the general tone increased by tinc- 
ture of nux vomica. The oil is most easily borne when given 
in emulsion, and may be advantageously combined with lacto- 
phosphate of lime or with the hypophosphites. 

Such symptoms as constipation, diarrhoea, and vomiting 
demand, of course, appropriate treatment. 



CHAPTER II. 
SCORBUTUS. 

Infantile scurvy is a constitutional disease occurring usu- 
ally before the end of the second year, depending upon con- 
tinued faulty feeding, and presenting a well-defined complex 
of symptoms. The characteristic features are : First, immo- 
bility, progressing to pseudoparalysis ; intense hyperesthesia ; 
and general swelling, situated most frequently in the legs, 
but not limited to these members ; the investing skin is shiny 
and tense, but there is neither oedema nor local heat, and 
subsidence of the general swelling reveals deep fusiform 
thickening about the shafts of the long bones in the neigh- 
borhood of the joints. In extreme cases there is a tendency 
to fracture near the epiphysis. Second, the gums about 
erupted teeth are swollen and purple in color and, in marked 
cases, become spongy and readily bleed. Third, a rapid dis- 
appearance of all symptoms upon the institution of a proper, 
antiscorbutic diet. 

Etiology. — Scurvy shows no preference for sex, occurs at 
any season, in any climate or locality, amidst the best or 
worst hygienic surroundings, and in every class, though 
wealth furnishes by far the larger number of cases. In the 
majority of instances the disease develops between the age 
of six months and the end of the second year, though this 
limit is by no means a fixed one ; it is closely confined to 
artificially fed infants, there being but two recorded cases in 
nurslings. 

The direct causal factor is the continued use of food that 
lacks some essential nutritive elements or presents them in a 

in 



112 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

form not readily assimilable. An analysis of the reported 
cases shows that the patients have received a great variety of 
foods, and, if the few instances in which the only traceable 
cause is simple poverty in diet be eliminated, the sole factor 
that is uniformly present is the absence of the quality of 
freshness, — the food is not " live." To put the whole question 
in a few words, the cause of scurvy in infants is the continued 
deprivation of fresh food. 

The faulty foods may be classed in the order of their 
potency : 

First, the different proprietary infants' foods administered 
without the addition of cows' milk. These foods are respon- 
sible for the greatest number of cases, and which variety most 
readily induces the disease depends chiefly upon the extent 
of employment or the fashion at the time. 

Second, proprietary foods employed with the addition of 
insufficient quantities of cows' milk. 

Third, oatmeal or wheat gruel, barley and other farinacese, 
administered with water alone, or with water and insufficient 
cows' milk. 

Fourth, condensed milk and water. 

Fifth, sterilized milk. Properly modified milk mixtures 
subjected to a temperature of 21 2° F. from thirty minutes to 
an hour or more. 

Sixth, too dilute milk and cream mixtures. Laboratory 
mixtures with too low albuminoid percentage. 

Consideration of these groups furnishes an explanation of 
the greater frequency of scurvy in infants reared in luxury 
than in the very poor. The proprietary foods, being expen- 
sive, are little used by the latter class ; the processes of modi- 
fying and sterilizing cows' milk are troublesome and require 
too much thought and time, and the cares of housework and 
bread-winning prevent regular and accurate artificial feeding. 
In consequence the child of poverty is fed upon milk either 



SCORBUTUS. 113 

diluted or pure, as the chance may be, and, if this be not at 
hand, upon tea, potatoes, bits of bread, or other table food — 
a bad diet, and one which often leads to rickets or dangerous 
gastro-intestinal disorders, but which is too varied and " live " 
to produce scurvy. 

The variations in the diet usually made at the end of the 
second year also explain the in frequency of the development 
of the disease after this age. 

The essential cause of scurvy is unknown, but it is certain 
that it is some peculiar deprivation, and that the needed 
elements are present in fresh milk and the juice of fresh, ripe 
fruits. 

Pathological Anatomy. — Very few postmortem examina- 
tions are on record ; in fact, since infantile scurvy has been 
recognized as a distinct condition, and its treatment established, 
a favorable outcome is to be expected in the vast majority of 
instances. Of twenty-six cases that have come under my 
own observation during the past ten years, but one terminated 
fatally. This, my second diagnosed case, occurred in 1891. 

The patient, a boy fifteen months old, had been ill nearly 
four months before I was consulted, and was so far reduced 
in flesh and general strength, was so anaemic, and had such 
grave intestinal complications, that all efforts at treatment 
were unsuccessful. After death the body showed extreme 
emaciation, the skin was inelastic, pale, and presented numer- 
ous ecchymotic spots of varying size. The gums about the 
eight incisor teeth that had been cut were deep purple in color, 
very much swollen and spongy, and covered with blood. 
Both legs were much swollen above the ankle joints, the right 
to the greater extent. On section, the lower third of the 
right tibia was found to be surrounded beneath the periosteum 
by a thick mass of dark, grumous blood ; the lower epiphysis 
was detached and the distal end of the shaft, macerated and 
eroded, lay free in the disintegrating blood clot. The lower 



114 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

third of the left tibia was surrounded by a similar, though 
less extensive, subperiosteal blood effusion ; it was not fractured. 
The fibulae, femora, and bones of the upper extremities were 
normal. 

The intestines contained blood and blood-stained mucus, 
and the mucous membrane was thickened and studded, es- 
pecially in the colon, with follicular ulcers. 

Microscopic examination of the bone and periosteum showed 
no lesion beyond the mechanical one at the seat of fracture, 
and the same was true of sections from the liver, spleen, and 
kidneys, and of the blood. 

These findings correspond very closely to those detailed by 
Barlow and Northrup, and the anatomical lesions of the dis- 
ease may be briefly stated to be chiefly due to hemorrhage, 
the most characteristic being the subperiosteal blood effusions 
about the shafts of the femora and tibiae, sometimes of the 
long bones of the arms, and occasionally those of the cranium 
and thorax. 

Bleeding may also occur into the subcutaneous tissue (ec- 
chymosis), and from the nose, stomach, bowels, and bladder. 

J. J. Thomas * asserts that the kidneys are frequently in- 
volved in infantile scurvy, and attributes the lesion, catarrhal 
nephritis, to the presence of an irritant in the blood, which, 
by its effects upon the walls of the renal vessels, produces 
hemorrhages. While this is a condition one would naturally 
expect, it was absent in my single fatal case, and in none of 
the others was either albumin or blood present in the urine 
during the course of the disease. 

Symptoms. — The scorbutic condition is produced gradu- 
ally after weeks or months of improper feeding ; there may 
be slowly increasing evidences of impaired nutrition before 
the characteristic symptoms appear, but usually these sud- 

*" Boston Med. and Surg. Jour.," Sept. 3, 1896. 



SCORBUTUS. I I 5 

denly interrupt a state of apparent health. It is first noted 
that the infant is content only when perfectly quiescent ; that 
he screams when lifted in the nurse's arms, or that he ceases 
to creep or walk. Soon it becomes evident that crying is pro- 
duced most readily by movements involving the legs, and that 
either one or both limbs are held fixed, the thigh being drawn 
up toward the abdomen, the leg flexed and the foot drooped. 
Next swelling appears above the knee or ankle joints, and 
immobility and tenderness increase ; the latter to such an ex- 
tent that the patient stops crying only while lying undisturbed 
on a pillow. Then the gums about any teeth that may be 
cut become purple in color ; in the beginning there is merely 
a narrow line of this discoloration, but it rapidly extends ; 
the gum swells, grows spongy, and bleeds at the lightest 
touch. With these special symptoms there is moderate gen- 
eral debility and loss of flesh, restless sleep, impaired appe- 
tite, a tendency to constipation, a diminished flow of high- 
colored, lateritious urine, and in some cases moderate eleva- 
tion of temperature, though absence of fever is the rule. 

Without treatment, or when badly managed, the disease 
runs a chronic course, and the symptoms slowly but steadily 
increase in gravity, until emaciation becomes extreme, pe- 
techial spots appear on the surface, the swollen gums overlap 
the teeth, and there is a constant oozing of blood. The 
immobility, hyperaesthesia, and swelling affect the arms as 
well as the legs, epiphyseal separations may take place, and 
the child, irritable and prostrated, lies passive upon the bed, 
dreading the slightest attempts at movement or even the 
approach of its nurse. 

These symptoms deserve a more detailed consideration, in 
the order of their development. 

Hyperaesthesia is almost invariably the initial symptom ; it 
appears in and may be limited to one leg, but often involves 
both. The infant first exhibits sensation of pain by changes 



Il6 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

in facial expression or by crying when the affected member is 
moved in changing the napkin or in arranging the stockings 
and dress. If the child be old enough to creep, stand, or 
walk, it excites the mother's suspicion that something is 
wrong, by suddenly becoming inactive, and by lamentations 
when induced to attempt previously enjoyed use of the legs. 
The tenderness increases steadily in degree, and, if primarily 
seated in one limb, extends to its fellow, and, in severe, long- 
standing cases, to one or both arms ; the little patient becomes 
helpless, suffers agony during the trifling movements neces- 
sary in making the toilet, and even anticipates pain and 
screams on the approach of the most gentle attendant. The 
characteristic of the pain is its production solely by move- 
ments of the parts involved, and, if the element of dread can 
be eliminated, moderately firm pressure upon or friction of 
the surface is readily borne. 

Immobility is the natural sequence of hyperesthesia, de- 
velops almost simultaneously, and with it increases in degree 
and extent. The decubitus is quite typical ; the infant lies 
on its side with the trunk thrown a little forward, the thigh 
drawn half-way up to the abdomen, the leg semi-flexed, and 
the foot drooped. When long maintained, this posture pro- 
duces slight oedema of the dorsum of the foot ; this is not 
sufficient to show pitting on pressure, though the skin looks 
puffy and is shiny. When the upper extremities are affected, 
the forearm is semi-flexed and rests on the trunk. This pos- 
ture is maintained for hours, with no attempt at movement 
and no complaint while undisturbed. 

The immobility is not paralytic in character, and if, despite 
the suffering produced, the limbs be manipulated, the joints 
are always found to be readily movable and free from stiff- 
ness. 

Swelling of the soft tissues about the bones is a common 
feature ; it varies in degree, though never very marked, and 



SCORBUTUS. I I 7 

is quite distributed, spreading over the area ot the bone 
affected ; thus, when the femur is involved the tumefaction 
extends from the knee nearly to the hip-joint ; when the tibia, 
from the ankle nearly to the knee ; if the arm bones are 
affected, swelling", while present, is less noticeable. The 
swelling is greatest over the distal end of the bones. It 
never involves the joint. 

Any pressure that does not move the limb is painless, there 
is no pitting, the skin is normal in color, and there is no in- 
creased local heat. 

As the case progresses the tumefaction subsides to a 
certain extent, tends to become limited to the lower third of 
the bone, and, beneath it, deep pressure reveals a firm fusiform 
enlargement of the shaft ; this is due to subperiosteal hemor- 
rhage, and varies greatly in extent in different cases. 

Lesions of the gums are observed only in cases in which 
one or more teeth have been cut ; they appear early, but 
often escape attention until sufficiently far advanced for hem- 
orrhage to take place. Primarily the gum margin about the 
necks of the teeth becomes deep red in color and slightly 
swollen ; soon the color changes to deep purple, the area of 
discoloration extends, the swelling increases, and ultimately 
the whole alveolar mucous membrane in the neighborhood 
of erupted teeth becomes ecchymotic ; the swelling is so 
extreme that the thickened gum margin overlaps the teeth ; 
the tissue is spongy, and hemorrhage is produced by the 
lightest touch or takes place spontaneously, blood constantly 
oozing in small quantities. Rarely sloughing occurs ; and 
occasionally, when the gum lesions are very marked, the teeth 
are temporarily loosened in their sockets ; they should be 
maintained in position, if possible, however, since they become 
firmly set again as the patient recovers. 

The general features are very diverse in degree of promi- 
nence. Often, when the scurvy is mild in grade, the infant 



115 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

is seemingly so well nourished and in such apparent health 
that the parents are surprised at the sudden development of 
local symptoms. Usually, however, even in these cases, the 
trained observer is able to detect evidences of malnutrition in 
the slight anaemia and muscle flabbiness. 

In well-marked instances there is emaciation ; dry, pale, or 
sallow skin ; debility, indicated by an irritable weak pulse and 
loss of muscle tone ; the tongue is lightly coated, the appetite 
capricious, and the bowels tend to constipation, the evacu- 
ations being rather scanty and clay- colored, showing deficient 
biliary secretion. Occasionally there is diarrhoea with green- 
ish, mucoid discharges, and at times the faeces contain blood. 
There may be more active indications of gastric indigestion, 
and very frequently there is an antecedent history of great 
difficulty in feeding on account of proneness to gastro- 
intestinal disturbance. 

Fever is not a symptom of scurvy, and, when present, is 
due to some accidental complication, as intercurrent acute 
intestinal catarrh. Under these circumstances the temperature 
is generally but moderately elevated, the thermometer ranging 
from a little above normal to ioo° or ioi° F. 

The urine is diminished in quantity, high-colored, often 
laden with urates, and increased in gravity. It has been 
asserted that albumin is frequently present and that the 
evidences of nephritis have been observed, but this is not 
borne out by my own experience. In grave cases there may 
be haematuria. 

Hemorrhage is a late feature, appearing after prostration is 
advanced and the blood crasis has deteriorated. It takes 
place first in the subcutaneous areolar tissue, especially in 
dependent parts of the body, and beneath the mucous mem- 
brane of the mouth. The ecchymotic spots are deep purple 
in color and range in size from that of a pin's head to patches 
one-fourth of an inch or more in diameter. 



SCORBUTUS. I I 9 

Bleeding from the gums has been already mentioned, and 
is an earlier symptom than subcutaneous ecchymosis. Later, 
epistaxis and haematuria may be observed, and, much more 
frequently, hemorrhage from the bowels, the leakage either 
merely staining the discharges from the rectum, or appearing 
as pure, though dark-colored and altered blood. The loss of 
blood directly increases the cachectic condition noted in 
severe cases, and, if at all profuse, plays an important part in 
exhausting the vitality in fatal cases. 

Fracture of the femur, tibia, or humerus is a late symptom, 
and shows an extremely grave type of affection. Separation 
at the lower third of the tibia existed in my single fatal case, 
and I know of no instance of recovery after its occurrence. 
In fact, it is doubtful if reunion of the soft, macerated, and 
eroded lower end of the shaft of the bone with its epiphysis 
could be accomplished, even granting the possibility of the 
infant's recovery from the condition of extreme prostration 
and malnutrition that is invariably present before fracture 
takes place. 

The bone lesion gives rise to characteristic deformity ; 
when the femur is involved, there is a distinct downward bend 
in the thigh, situated a short distance above the knee joint, 
and due to weight traction of the part of the limb below the 
seat of separation ; with the tibia the same bending is observed 
above the ankle joint, but it is less in degree, because the 
fibula acts as a partial splint and the depressing weight is not 
so great. Palpation does not yield crepitation, and it is 
difficult to feel the end of the bone through the surrounding 
soft tissues and the mass of extravasated blood. 

Diagnosis. — As the greater number of scurvy cases are 
quite typical, the diagnosis is usually attended with little 
difficulty. 

The distinguishing features are : The development in in- 
fants from six months to two years old — after the prolonged 



120 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

use of unsuitable food — of extreme hyperesthesia and immo- 
bility of the limbs ; swelling of the thigh above the knee 
joint and of the leg above the ankle joint; fusiform enlarge- 
ment of the lower third of the shaft of the femur and tibia ; 
deep purple discoloration (ecchymosis), swelling, and spongi- 
ness of, and hemorrhage from, the gums surrounding erupted 
teeth ; general cachexia and anaemia ; and, finally, — the test 
feature, — rapid disappearance of symptoms and complete 
recovery following the adoption of an antiscorbutic diet, and 
— the negative symptom — non-involvement of the joints. 

The pain produced by movement and the immobility of the 
limbs are responsible for most of the errors in diagnosis, 
scurvy being frequently mistaken for rheumatism, hip-joint 
disease, paralysis, and affections of the spine. 

Considering the very uniform and characteristic complex of 
symptoms in scurvy, it is difficult to understand why this con- 
fusion should occur, but I have seen two cases in which a 
reputable surgeon had applied dressings for hip disease during 
a period of four and six weeks, and many in which counsel 
was requested because a supposed rheumatic attack obstinately 
resisted every method of treatment. However, since the 
disease has been more carefully studied, illustrative cases 
reported, and the subject given a place in text-books, mistakes 
in diagnosis are becoming more and more infrequent. 

The question of the relation of scurvy and rickets has been 
much discussed. Before the former disease had been carefully 
studied rickets was supposed to uniformly precede or accom- 
pany it, and prior to the publication of the observations of 
Cheadle and Barlow it was classed as "acute rickets." Both 
diseases develop during infancy, and both are caused by food 
that is deficient in certain essential qualities, but here the 
similarity ends ; for the lesions of rickets are found in the 
bone tissue, those of scurvy in the blood-vessels, and, while 
the effects of these are readily and completely removable in 



SCORBUTUS. I 2 I 

scurvy, in rickets their mark is left permanently in bone thick- 
ening and deformity. Again, alterations in diet that quickly 
terminate scurvy are inoperative in rickets. The two condi- 
tions, therefore, are not generically related ; one may appear 
without the other, or they may coexist in the same patient, 
though such an association is exceptional in my experience. 

The symptoms of rickets show little similarity to those of 
scurvy and make the differentiation an easy matter. The 
most uniformly present and characteristic, in the type of cases 
in which there is most likelihood of confusion, are profuse 
perspiration about the head and chest, anaemia and evidences 
of malnutrition, delayed dentition, enlargement of the joints, 
bending of the long bones, craniotabes, misshapen head with 
prominence of frontal and parietal bones, rachitic rosary, 
deformity of thorax with depressed ribs and projecting, dis- 
torted sternum, and prominent abdomen. 

Purpura may be distinguished from scurvy by its etiology, 
unsuitable food not being an essential cause, and by the 
absence of hyperesthesia, immobility, spongy, bleeding gums, 
and deep subperiosteal hemorrhage. The leakage of blood 
in purpura has a tendency to be general and more superficial, 
being most marked in the subcutaneous tissue and from the 
various mucous surfaces and the kidneys. 

Prognosis. — When treatment is not guided by a correct 
diagnosis, scurvy runs a protracted course, and the patient 
gradually passes into a condition of such profound cachexia 
that death may take place from exhaustion. On the other 
hand, prompt detection and judicious management almost cer- 
tainly lead to rapid recovery, improvement beginning after a 
few days and all symptoms disappearing in from two to three 
weeks. 

The following table of twenty-six cases occurring in my 
own practice is of interest as an illustration of the clinical 
features in infantile scurvy of the type ordinarily encountered : 



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27 



125 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Dangerous symptoms are extreme anaemia and prostration, 
epiphyseal separation, the appearance of petechial spots, the 
expulsion of blood from the bowels, and hematuria. Extreme 
gastric irritability, making feeding difficult, and the intercur- 
rence of enteric catarrh materially add to the gravity of the 
prognosis. 

Treatment. — The management of scurvy is very simple, 
depending entirely upon the substitution of a fresh, antiscor- 
butic diet for whatever form of unsuitable food may have been 
the causal factor. If a proprietary food has been employed, 
it must be abandoned ; sterilization must be discontinued as a 
process of preparation ; condensed milk or food too rich in 
farinaceous material must be changed to a properly modified, 
untreated, cows' milk mixture, and if the food has been simply 
deficient in proteids, it must be strengthened so far as the 
digestive powers admit, and any deficiency supplemented by 
the use of some other form of albuminoid, as raw-beef juice. 

Briefly stated, the essential treatment is the employment of 
a food composed of cows' milk, cream, water, and milk sugar, 
properly proportioned to the age of the infant, and given, so 
far as the cream and milk are concerned, in the natural, fresh 
state : i. e., not passed through the separator and not sterilized. 

Pasteurization and predigestion at a temperature of 1 1 5 ° F. 
are admissible in certain cases, but should never be employed 
when the cream and milk are carefully handled at the dairy 
and can be kept clean and sound, and when the infant's 
digestion is even moderately active. 

The juice of fresh ripe fruit — orange juice especially — is a 
useful addition to the diet, and when, as is usually the case, it 
can be taken without producing diarrhoea, is an efficient aid 
to rapid recovery. 

For scurvy in an infant of eight months an appropriate food 
schedule is : 

First meal, 7 a.m. — 



SCORBUTUS. I29 

Cream, f 3 ss 

Milk, fgivss 

Milk sugar, %} 

Water, f^iij. 

At 9 a.m. — One to two teaspoonfuls of fresh orange juice, 
according to effect on bowels. 

Second meal, 10.30 a.m. — Same as first. 

At 11.30 a.m. — Two teaspoonfuls of raw-beef juice, free 
from fat and with a little salt. 

At 1 p.m. — One to two teaspoonfuls of fresh orange juice. 

Third meal, 2 p.m. — Same as first. 

At 3 p.m. — Two teaspoonfuls of raw-beef juice with salt. 

At 5 p.m. — One to two teaspoonfuls of fresh orange juice. 

Fourth meal, 6 p.m. — Same as first. 

At 8 p.m. — Two teaspoonfuls of raw-beef juice with salt. 

Fifth meal, 10 p.m. — Same as first. 

If orange juice cannot be obtained, or should it disagree, 
good substitutes are two to four teaspoonfuls of scraped ripe 
apple (raw), two teaspoonfuls of fresh grape juice, or six solid 
grapes from which the skins and seeds have been removed. 

In addition to alteration of the diet, very little treatment is 
necessary. Gentle inunction of the limbs with warm olive 
oil may contribute to the comfort of the patient, and some 
acceptable preparation of iron, as the ferrated elixir of cin- 
chona, will assist in restoring the strength and building up the 
blood. If there be great prostration, strychnia and alcoholic 
stimulants should be administered, and all complications must 
be met as they arise. 



CHAPTER III. 
RACHITIS. 

Rickets is a constitutional disease characterized by marked 
impairment of general nutrition, a peculiar softening and ar- 
rest of development of the bones with enlargement of their 
articulating extremities, broadening of the proliferating carti- 
laginous zone, relaxation of the ligaments about the joints, 
allowing of knock-knee and flat-foot, and various secondary 
alterations in the viscera. Additional symptoms are : Muscle 
weakness, resembling, and in severe cases often mistaken for, 
paralysis ; nerve irritability, evidenced by such complications 
as laryngismus stridulus ; profuse sweating; anaemia; and a 
tendency to catarrhal affections. The most striking features 
are the osseous softening, permitting the production of special 
deformities which become more or less fixed as the disease 
runs its course and the bones again harden, and the arrest ol 
development, causing stunting of the frame. 

Etiology. — Rickets, while an easily preventable disease, 
is of frequent occurrence, asylum and hospital statistics 
showing that from 28 to 30 per cent, of children under five 
years of age, and of the class that enter such institutions, 
are subjects of the disease in its mild or incipient form ; the 
strongly marked, grave type being comparatively uncommon 
in this country. 

The disease shows no preference for sex. It is not con- 
fined to any class or race, but is more frequently encountered 
among the poor than among the rich; in squalid, over- 
crowded portions of cities than in the open country, and is 
much more prevalent in negroes than in whites ; the latter 

130 



RACHITIS. I 3 I 

being due to the peculiar tendency to malnutrition and lack 
of resisting power inherent in the African race. 

It may develop during intra-uterine life, but usually the 
initial symptoms are not observed before the seventh month ; 
the greatest number of cases arises in the second half of the 
first year, and the second and third years ; after this, to the 
end of the fifth year, the frequency diminishes steadily and 
rapidly, and still later in life it originates with great rarity. 

Rickets is never inherited ; rachitic parents may have 
rachitic offspring, but one must look to the coincident preva- 
lence of the disease and to impairment of the function of 
nutrition, which can be inherited, for an explanation of the 
causation, rather than to direct transmission. Parents weak- 
ened by overwork, bad and scanty feeding, dissipation, and 
exhausting diseases — as tuberculosis and, especially, syphilis 
— are apt to produce children showing evidences of malnu- 
trition and predisposed to the development of rickets under 
the influence of certain well-defined conditions. These are 
improper feeding, residence in ill-ventilated, damp, dark, and 
overcrowded rooms, and want of personal cleanliness. As 
to improper food, the most potent of these factors, the fault 
may be either in too prolonged feeding from a breast that 
yields an insufficient quantity or a poor quality of milk, or in 
the administration of unsuitable artificial food. With substi- 
tute foods the error usually committed is in the direction of 
over- rather than under-feeding. The tendency is to give strong 
food, with the idea of producing strength, and to make addi- 
tions to meet the feebleness of the infant, without reference to 
the capacity for digestion and assimilation, which diminishes in 
direct proportion to the general loss of tone. Too often there 
is a total disregard or ignorance of the fact that a dilute 
food is often a better tissue-builder because it is more readily 
and completely digested and absorbed. This is seen espe- 
cially among the poor, whose infants of a year or less are fed 



132 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

at the table on tea, bread, potatoes, and even meat, on the 
supposition that they ought to agree because they are suited 
to the older members of the family. Among the well-to-do 
the fault lies in employing insufficiently diluted cows' milk 
mixtures or in adding too much farinaceous or proprietary 
food to the diet. Of the different artificial foods, the fari- 
naceae, the proprietary foods in which the starch has been 
incompletely converted, and condensed milk are the most 
active etiologically. All these are deficient in animal fat, the 
first two in proteids and phosphate of lime, for it has been 
proved by clinical observation and experiments on animals 
that the main factor in the production of rickets is the failure 
to receive in, or assimilate from, the food supplied these three 
essential ingredients — animal fats particularly, proteids and 
salts to a less, though appreciable, extent. 

The exciting causes are all influences tending rapidly to 
lower the vitality of a child with previously impaired nutri- 
tion ; as an attack of measles, varicella, or any of the acute 
exanthemata, a severe and continued bronchitis, an acute 
gastro-intestinal catarrh, or any protracted and exhausting 
disease. 

Morbid Anatomy. — Pathologically, rickets is a dyscrasia 
affecting the nutrition of various tissues of the body, and 
causing lesions of the bones w r hich are probably inflammatory 
in nature. These osseous changes pass through three stages 
during the course of the disease : (1) Proliferation and altered 
nutrition of the cartilage and periosteum ; (2) deformity ; (3) 
reconstruction. 

1. Normally the long bones increase in length by the 
formation of bone in the cartilage between the diaphysis and 
epiphysis ; in thickness, by a similar formation beneath the 
periosteum. The flat and short bones grow in breadth by 
the development and ossification of their cartilaginous borders, 
and in thickness from the periosteum. The cartilage consists 



RACHITIS. 133 

of a matrix containing cells ; the distal and greater portion 
presents the appearance of a white zone, and is made up of 
dense hyaline matter and a few cells ; passing inward, the 
cells become more numerous and the matrix less, until, close 
to the bone, there is a layer composed almost entirely of car- 
tilage cells. This, the proliferating zone, has very little 
depth, and shows as a thin layer of reddish-gray color upon 
the end of the bone shaft. 

Increase in thickness is accomplished in a soft, vascular, 
germinal tissue which springs from the under surface of the 
periosteum, rapidly receives lime salts, and is transformed into 
bone ; this germinal tissue is composed principally of capil- 
laries originating in the fibrous tissue of the periosteum, and 
is a very thin, scarcely visible substance, subject to constant 
changes from rapid ossification. 

In rickets both conditions of growth are vastly different. 
The proliferating zone, crowded with cartilage cells, is greatly 
increased in size, occupies nearly the whole of the epiphyseal 
cartilage, forms a broad, soft, translucent, "-ravish mass, and 
produces the characteristic swelling about the joints. With 
these changes in the cartilage there is a modification or com- 
plete arrest of the ossifying process. Usually, however, 
there is some effort at bone formation. The Haversian canals, 
surrounded by capillary loops, extend irregularly from the 
extremity of the shaft into the proliferating zone, the matrix 
being absorbed and intervening cell-groups appropriated. At 
the same time granules and masses of lime are deposited 
throughout the cartilage and a few spiculae and nodules of 
true bone spring from the shaft. The subperiosteal tissue, 
under the irritating influence of the disease, increases more 
rapidly than in health and, ossification taking place imperfectly 
or being suspended entirely, becomes a thick layer, resembling 
spleen-pulp in color and consistence. This appearance is due 
to the growth of very numerous large and thin-walled 



134 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

capillaries from the under surface of the periosteum. Over 
the cranial bones the vascular outgrowth is much less uniform 
than over the shafts of the long bones, being thicker in some 
places than in others ; this explains certain peculiarities noted 
in these bones during the later stages of the disease. Some 
attempt at ossification takes place in this exuberant tissue, 
but it is abortive, and results in the formation of vascular and 
fragile osteophytes. Preformed bone is not softened by 
rickets, but, after the onset of the disease, the new layers are 
not consolidated as they form, and, the old layers being 
destroyed by the progressive formation of medullary cavities, 
the result is a soft, brittle osseous tissue. 

In this stage the bone becomes bluish or dark-red in color 
from excessive vascularity, and the normal relation of inor- 
ganic to organic constituents (two to one) is altered, the 
organic matter greatly preponderating, though the degree of 
excess varies with the severity of the disease. This also 
influences the distribution ; in mild cases a few bones only are 
affected, while in grave types the whole skeleton may be 
involved. 

2. Deformities differ in degree and vary in the period of their 
appearance, according to the severity of the attack and the 
age of the patient ; softening and consequent distortion 
occurring much more rapidly and much more extensively in 
infants than in older children, probably because they are more 
profoundly influenced by malnutrition and its consequences. 

The bones most frequently involved are those of the 
cranium ; the ribs, especially at their sternal ends ; and the 
radii at their distal extremities, and, although the disease may 
involve the general skeleton, these bones are the first and 
most markedly affected. 

The deformities embrace alteration in shape, enlargements 
of articulating extremities, rounding of projecting points, and 
curvatures and twists of the bone shafts due to the pressure 



RACHITIS. 



135 



of position and weight of the body, or to muscular action. 
Rickets also arrests the development of the skeleton, both 
during and after the active period of disease, so that rachitic 
children, independently of curvatures, have less than the 
average height after reaching adult life. The stunting is 
greatest in the bones of the face, pelvis, and legs. 

The bones of the skull are sub- 
ject to certain special changes. 
Their edges, which correspond 
to the epiphyseal cartilages of 
the long bones, undergo a simi- 
lar proliferation and thickening. 
This, together with delayed union 
of the sutures, produces grooves 
that are appreciable to palpation 
and are often visible. Retarded 
ossification also causes a large 
size and increased patency of the 
fontanelles, and postpones their 
closing until long after the usual 
time. The cranium is misshapen, 
and measurement shows an 
actual increase in size, though 
the enlargement is more appa- 
rent than real on account of the 
stunting of the facial bones. In 
addition, the special change 
craniotabes occurs. This is 

almost peculiar to very early infancy, being usually noted 
before the eighth month or the end of the first year. It 
consists in thinning of isolated areas of the softened bone by 
pressure from the brain within and the pillow without, and is, 
in consequence, most marked in the occipital and the posterior 
portions of the parietal bones. The thinned spots are to be 




Fig. 5.— The Deformities of 
Rickets. 



I36 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

searched for over the body of the bone ; they are soft and 
yielding to pressure, and in the cadaver are translucent when 
the bone is held between the eye and a light. They differ 
in degree, in some cases being simple depressions resembling 
erosions, a thin bony layer remaining, while in others the 
absorption of bone is complete and the brain is covered only 
by the dura mater and scalp. 

Dentition is markedly affected by rickets. The process is 
not only greatly delayed, but such teeth as do appear during 
the course of the disease are deficient in enamel, break and 
crumble easily, and decay readily. 

3. Reconstruction. During the first and second stages the 
vascular periosteum is drawn tightly over the convexities of 
the bones, this pressure diminishing the hyperemia and the 
amount of exudation ; over the concavities the membrane is 
loose, is intensely hyperaemic, and the interspace between it 
and the bone is filled with a soft gelatiniform exudate. Repair 
begins with the deposition of earthy salts from the blood into 
whatever open space there is beneath the periosteum, and 
takes place most easily and rapidly where there has been free 
exudation with no compression of the capillaries : that is, on 
the concave surfaces of the bones, the long bones especially. 
At first the lime salts are deposited in hard compact masses, 
like the callus formed about a fracture, and with small and 
imperfectly formed Haversian canals and lacunae ; later, after 
complete recovery from the disease, there is a return to nor- 
mal bone formation. 

Recovery is always protracted : the proliferation of cartilage 
and periosteum slowly ceases, hyperemia lessens, and the 
osseous system gradually resumes its normal function and 
development. 

The ligaments are relaxed and flabby, giving unusual 
mobility to the joints, and knock-knee and flat-foot are often 
present, even in cases of such mild type that there is very little 



RACHITIS. I37 

bone deformity. The fibrous bands uniting the vertebrae parti- 
cipate in the relaxation, and this, associated with rachitic 
changes in the bones and intervertebral cartilages, permits 
backward, forward, or lateral curvatures of the spinal column 
to take place. 

While the most prominent lesions of rickets are seated 
in the bones, the disease, being systemic, also affects the 
soft tissues and viscera. 

Emaciation is not very decided, though the muscles may 
become shrunken and flabby, partly from the general mal- 
nutrition and partly from want of use ; under the microscope 
their fibres appear softer and paler than natural and the striae 
are very indistinctly marked. 

Anaemia is present in severe cases, and in all instances the 
mucous membranes generally, but especially those lining the 
gastro-intestinal canal and the bronchial tubes, are prone to 
show the evidences of a low grade of catarrhal inflammation. 

The liver is often enlarged, hard and elastic to the touch, 
anaemic, and pale in color. The fibroid tissue is universally 
increased ; in the smaller portal canals the fibroid sheath is 
doubled in thickness, and the yellowish acini are bounded by 
a thin pink or gray line. In the acini the cells are more 
closely packed than normal. Sometimes, as in other condi- 
tions attended by malnutrition, the enlargement of the liver 
is due to fatty infiltration ; at others the organ, while unaltered, 
gives a false impression of increase in bulk by occupying an 
unnaturally low position in the abdomen, being carried down- 
ward by the depressing force of the deformed thoracic walls. 

The spleen is more frequently increased in size than the 
liver. In some instances it is merely perceptible below the 
margin of the ribs ; in others, it extends downward as far as 
the mid-line of the abdomen, measuring as much as eight 
inches in vertical and four inches in horizontal diameter. The 
viscus is indurated ; its substance is tough and elastic and 



I38 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

contains very little blood. It is deep red or purple in color, 
the surface is mottled with smooth white spots, — enlarged 
Malpighian corpuscles, — and under the microscope the tra- 
becular are found to be irregularly swollen, the walls of the 
meshes are thickened, and the corpuscles are greatly increased 
in number and crowded together. 

The lymph glands, especially the mesenteric glands, are 
quite uniformly enlarged and hardened ; they are white and 
opaque and their corpuscular elements are greatly augmented. 

The brain -may be enlarged, and hydrocephalus sometimes 
occurs as a complication, but it is difficult to establish any 
pathological connection between these conditions and the 
rachitic dyscrasia. 

Distortion of the thorax consequent upon softening of the 
ribs, and enlargement of the costochondral articulations, pro- 
duce special lesions of the lungs, which are invariably present 
and always occupy the same position in the pulmonary tissue. 
These are emphysema and collapse. The emphysema is due 
to overdistention of certain air vesicles from unequal thoracic 
expansion during the inspiratory act, and involves nearly an 
inch of the whole anterior free border of both lungs. The 
collapsed tissue forms a groove immediately outside of the 
emphysematous margin, separating it from the healthy lung ; 
it is produced by direct pressure from, and corresponds to, 
the line of the enlarged sternal ends of the ribs. Isolated 
areas of collapse may also occur throughout the lung, as a 
result of a plug of mucus entering a small tube when there 
is a complicating bronchitis. 

The enlarged extremity of the fifth rib coming in contact 
with the pericardium over the apex of the left ventricle 
produces a circumscribed opacity — "white patch" — of the 
membrane. The same may be formed on the capsule of the 
spleen by attrition against a projecting rib nodule during the 
respiratory movements of the diaphragm ; in this position the 



RACHITIS. I39 

opaque spot is distinguished from embolism by extending 
'only as deep as the fibrous investment of the organ. 

Symptoms. — The actual beginning of the disease is pre- 
ceded by a pre-rachitic stage, in which the patient presents 
symptoms closely allied to those of simple atrophy. These 
are prostration ; pale or muddy skin ; wasting of the general 
subcutaneous adipose tissue ; muscle flabbiness ; drowsiness 
and lethargy by day, and restlessness and broken sleep at 
night. Thirst is increased ; the appetite is usually voracious ; 
there is abdominal pain, and the action of the bowels is 
irregular, a day or two of relaxation being followed by an 
equal period of inactivity ; again, there may be obstinate 
constipation. The evacuations, which are usually voided 
with considerable straining, are extremely offensive, and 
consist of whitish, putty-like material mixed with mucus, and 
in some instances the food seems to pass through the alimen- 
tary canal with little change except in the way of putrefaction. 
The urine is passed in large quantities and abounds in 
phosphates. 

Sometimes if the infant be taking a large quantity of fat- 
forming food, the frame may be sufficiently rounded and 
plump, but the flesh is too soft and flabby. 

The onset of the disease is marked by two symptoms — 
perspiration, and a desire on the part of the child to lie cool 
at night. 

Sweating takes place from the skin of the head, or from 
the head, neck, and upper part of the chest ; it is almost 
uniformly profuse, the moisture standing in large drops upon 
the forehead and running down over the face, and is constant, 
though most extreme during sleep or when the little patient 
is excited or exposed to an elevated temperature. With the 
perspiration there is enlargement of the superficial veins of 
the forehead and of the jugular veins, and there ma}* be 
visible pulsation of the carotid arteries ; while, from irritation, 



I40 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

crops of miliaria appear upon the temples and close to the 
roots of the hair. 

In contrast to this overactivity of the skin of the upper 
part of the body, the abdomen and legs are usually dry and 
hot. 

The desire to lie cool at night is quite characteristic. Even 
in winter the child will kick off the bedclothes, or throw his 
naked legs outside of the coverlet, and the mother, with no idea 
of the meaning of the symptom, grows anxious and adopts 
the bag night-dress or other means to keep her child covered 
and prevent his taking cold. 

Tenderness, formerly considered an important initial symp- 
tom, may sometimes be elicited by pressure over the epi- 
physes, but it is not uniformly present even in severe cases, is 
absent in those of mild type, and if acute enough to cause 
the patient to scream when handled or to produce immobility 
of the limbs, is an indication of infantile scurvy rather than 
of rickets. 

These early features are accompanied by all the symptoms 
of the pre-rachitic stage, and by the changes in the osse'ous 
system, which soon become evident as deformities. The first 
bones to be affected are the cranial, the ribs, and the radii. 
Primarily in the long bones, the articulating extremities en- 
large at the point of junction of the shaft with the epiphysis ; 
both ends suffer, but the swelling is naturally most apparent 
at the superficial end. The ribs at their sternal ends are 
attacked early ; next the radii, at the wrists ; and, as a rule, 
the enlargement is more marked in the bones of the upper 
than of the lower extremities. The flat bones — cranium, 
scapulas, pelvis — are thickened, and there is softening of all 
the bones that may be involved, leading to the various distor- 
tions that characterize the disease. 

The extent of softening and deformity depends upon the 
gravity of the attack : if mild, the change is limited to the 



RACHITIS. 141 

bones of the skull, the ribs, and the radii ; if severe, all the 
bones of the frame suffer. In either case the relation between 
articular enlargement and softening varies, sometimes one, 
sometimes the other, being most prominent. 

CJiauges in the Bones of the Head and Face. — The cranium 
is increased in size, the veins of the scalp are distended, and, 
in marked cases, the growth of hair is scanty. In shape the 
head is either square or oblong, the antero-posterior diameter 
being increased ; the vertex is flattened and the forehead is 
high, square, and projecting, and is out of proportion to the 
face. The actual enlargement is exaggerated by the arrest 
of development of the upper jaw, malar bones, and face gen- 
erally. The surface is irregular, the rachitic thickening being 
greatest along the edges of the bones, and at the centres of 
the parietal and the bases of the temporal bones. Deep 
fissures indicate the position of the open sutures ; the fonta- 
nelles, especially the anterior, remain widely open long after 
the normal period of closing ; and over the occipital bone 
and the posterior portions of the parietal bones, isolated areas 
of osseous thinning — craniotabes — can be felt. These spots 
vary in size from one-eighth to one-third of an inch in diame- 
ter, and to the finger, which should always be gently applied 
in the search, they are perceived as depressions in the bone 
which are elastic, like stiff paper, or, when the absorption has 
been complete, feel like the surface of a fully distended 
bladder. 

With the general stunting of the bones of the face, special 
changes take place in the jaw bones, which affect the position 
of the teeth. The lower jaw becomes polygonal, with the 
alveoli inclined inward, the arch thus being shortened from 
before backward. This distortion is attributed to the action 
of the masseter, the mylo-hyoid, and the genio-glossus mus- 
cles, and to pressure from the lips. In the upper jaw the 
lateral pressure of the zygomatic arches elongates the bone 



142 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

and alters the shape of the arch and the position of the teeth. 
Hence the external incisors are forced into a lateral posi- 
tion, and, when the jaws are closed, the superior incisors and 
molars overlap the corresponding lower teeth in front and at 
the sides. 

The process of dentition is greatly influenced by rickets. 
Should the disease develop before the eruption of any teeth, 
their appearance is indefinitely delayed : if some teeth have 
been cut, further evolution is arrested and those present 
soon grow black from decay and become loose in their 
sockets. This retarding influence is peculiar to rickets, not 
being a feature of other diseases accompanied by impaired 
nutrition, as simple atrophy, scurvy, chronic diarrhoea, tuber- 
culosis, or congenital syphilis. 

Changes in the Ribs. — The "rachitic rosary" appears early 
in the disease. It is due to the enlargement of the costochon- 
dral articulations, and consists of a series of nodules extending 
from the clavicle to the base of the chest and resembling a 
row of large beads underneath the skin. 

Softening of the ribs permits of distortion by muscular 
action and by the force of external atmospheric pressure, in 
the absence of proper osseous resiliency. The resulting 
deformity is very characteristic ; the thorax, being flattened 
posteriorly and projecting sharply anteriorly, loses its normal 
rounded outline and becomes more or less triangular. From 
their vertebral attachment the ribs extend almost horizon- 
tally outward, then bend, at an acute angle, at the junction 
of the dorsal and lateral portions, and thence pass forward and 
inward toward the sternum. The costal cartilages curve out- 
ward before turning in to articulate with the sternum, and this 
bone is forced forward, increasing the antero-posterior diameter 
of the chest and producing the condition termed "pigeon- 
breast." The lateral diameter is greatest at the acute angle 
formed by the ribs, least at the costochondral junction. The 



RACHITIS. 143 

bending inward of the ribs and outward of the cartilages forms 
a depression on the antero-lateral aspect of the chest, extend- 
ing from the first to the ninth rib, and being deepest immedi- 
ately outside of the line of the rachitic rosary. On the left 
side the depression is less deep between the fourth and sixth 
ribs, on account of the partial support given the chest wall by 
the heart ; and on the right side the liver diminishes the depth 
of the groove below the sixth rib. On both sides, below the 
eighth or ninth rib, there is a more horizontal depression, — 
Harrison's groove, — which corresponds to the upper borders 
of the liver, stomach, and spleen ; these organs supporting the 
parietes and preventing their sinking in, under the external 
air pressure. During the inspiratory act the sternum is pressed 
forward, the abdomen expands, and all the grooves become 
more marked, presenting an appearance similar to that ob- 
served when a moderate obstruction to the entrance of air 
exists in the larynx or trachea. 

Changes in the Bones of the Upper Extremities. — Swelling of 
the distal extremity of the radius is one of the earliest symptoms 
of rickets, but the arm bones are less frequently curved and 
distorted than those of the legs. The radius and ulna may be 
bent outward and twisted on their long axis ; the humerus is 
sometimes bent, most often at the upper third, from the power- 
ful action of the deltoid muscle in lifting and supporting the 
arm. The clavicle may be curved in two directions : one back- 
ward, near the scapula ; the other and longer, near the sternum, 
in a forward and upward direction. The scapulae occasionally 
show thickened margins, like the other flat bones. The cur- 
vatures in the bones of the arms and in the clavicles are partly 
due to pressure occasioned by the child's supporting himself, 
while in a sitting posture, upon the hands held palms down- 
ward and pressed upon the bed or floor. 

Changes in the Vertebra. — The spine is bent by the weight 
of the shoulders and head. The degree of curvature is pro- 



144 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

portionate to the muscle weakness, and its direction depends 
upon whether the child can or cannot walk. In the latter 
case the anterior cervical curve is increased, and the normal 
backward curve from the first dorsal to the last lumbar ver- 
tebra is greatly exaggerated. The augmented cervical curve 
and attendant muscle weakness deprives the head of efficient 
support ; it therefore tends to fall backward, and gives a very 
characteristic attitude in the sitting posture. Lateral curva- 
tures are less common than the antero-posterior ; they depend 
upon position, and may be produced by the nurse habitually 
carrying the child over one arm. 

If the child be able to walk, the dorsal spine is bent back- 
ward, the lumbar forward. Usually the curvatures disappear 
when the patient lies down, or is lifted by the hands placed 
under the arms so as to take the weight of the head and 
shoulders from the spine ; but when the disease is severe, and 
so long continued that the vertebrae and intervening cartilages 
have become wedge-shaped, these curvatures either are with 
difficulty rectified by mechanical appliances or become perma- 
nent. 

In rare cases the curvature is sufficiently extreme to inter- 
fere, by compression, with the function of such important 
organs as the heart, lungs, or great vessels. 

Changes in the Pelvis. — Rachitic deformities of the pelvic 
bones are of great importance in the female, as they involve 
serious consequences in the event of future marriage. They 
produce various alterations in the shape of the outlets, but the 
tendency is to change the normal oval to a triangular form. 
Elongation of some and contraction of other diameters occur, 
when the child is standing, from the weight of the head, arms, 
and trunk ; the promontory of the sacrum, especially, being 
carried forward by this pressure, as it supports the weight of 
the spine. Again, the heads of the thigh bones in standing, 
and the tuberosities of the ischia in sitting, exert a double 



RACHITIS. 145 

pressure from below, and effect a narrowing of the outlet of 
the pelvis. 

The degree of deformity depends greatly upon the age of 
the patient at the time of the onset of the disease, or upon the 
completeness of the ossification, for the cartilages are less 
yielding than the bones themselves. 

Changes in the Bones of the Lower Extremities. — Beyond 
enlargement of the articulating extremities of the bones, the 
legs may escape deformity if the child has not walked before 
the rachitic changes beg-in. In such instances the muscles are 
flabby and the limbs are weak and look too short, but the 
bones remain straight. 

The distortion of the femur shows in a curving forward of 
the shaft if the infant has not walked ; this is due to the weight 
of the feet and legs pulling upon the lower end of the femur 
while the patient sits in the nurse's lap. If the child can walk, 
the curve is an exaggeration of the normal forward and out- 
ward bend ; at times the head of the bone is bent at an angle, 
acute or obtuse, to the shaft. 

The tibia, before walking, is curved outward, due to pres- 
sure upon the external malleolus as the infant sits cross-legged 
on the bed or floor. After walking, the weight of the body 
bends the bone at its lower third, the curve being abrupt and 
directed either anteriorly over the foot or laterally over the 
outer malleolus. 

In addition to softening and resultant deformity, the growth 
of the bones is arrested by rickets, both during the progress 
of the disease and after apparent recovery. The stunting is 
most constant and decided in the bones of the face, pelvis, and 
legs, though it may be apparent in all the members of the 
skeleton, and, when combined with curvature of the leg bones, 
accounts for the short stature of many adults who have suf- 
fered from the disease in childhood. The arrest in the growth 
and development of the pelvis is the most serious form of 



I46 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

stunting, as it may interfere with certain bladder operations in 
the child, and in the adult female is a grave complication during 
parturition. 

The articulations are involved in the enlargement of the 
extremities of the long bones, and become bulbous and knotted, 
the increase in size being exaggerated by wasting of the 
muscles. 

At the same time the ligaments surrounding the articulations 
and holding the bones together are relaxed, and the joints 
become loose and abnormally mobile. This relaxation is an 
early symptom, is often marked when the changes in the bones 
are slight, and may affect all the joints of the frame. In the 
lower extremities it greatly impedes walking and gives rise to 
knock-knee, eversion of the foot, or flat-foot. In the spine 
the weakness of the ligaments connecting the vertebrae with 
each other and with the sacrum, and the sacrum with the 
pelvis, combined with the same condition in the legs, produces 
the inability to hold the body upright and to walk, which are 
so typical of the disease. 

While the bone softening and distortion are in progress the 
profuse sweating continues ; the appetite may be excessive, 
but usually is diminished and capricious ; sick stomach sets 
in, with sour breath and acid eructations or vomit, and the 
bowels are either obstinately constipated or there is diarrhoea 
with offensive, liquid evacuations, green in color and contain- 
ing mucus. So soon as the gastro-intestinal disturbance 
begins, the patient, though sufficiently plump before, rapidly 
loses flesh, and any pre existing anaemia and weakness in- 
crease. The skin becomes pale and muddy, the face grows 
old, the eyes look large and lack speculation, and the general 
expression is one of indifference. If the muscle weakness be 
not great enough to prevent, the child will sit for hours with 
the legs stretched forward and the trunk supported by the 
arms, content to be inactive and undisturbed. The respiratory 



RACHITIS. 147 

movements are increased in frequency and labored, and if there 
be much softening and retraction of the ribs, every energy is 
devoted to the act of breathing, and the little sufferer has no 
breath to waste in complaining or crying. The abdomen is 
greatly distended and in marked contrast with the contracted 
chest. The enlargement is due to depression of the diaphragm, 
and, with it, of the liver and spleen ; to flatulent distention of 
the bowels, favored by weakness of the muscles of the intes- 
tinal walls and abdominal parietes ; and to shallowness of the 
pelvic cavity. In addition to being depressed downward, the 
liver and spleen may be enlarged. Enlargement of the spleen 
is more common and excessive than that of the liver, though 
the edges of the latter are often harder and sharper than normal. 
Under these conditions the lymphatic glands of the neck, arm- 
pits, and groins are increased in size, become easily perceptible 
as hard, readily movable nodules, and there is extreme emaci- 
ation and anaemia, with slight anasarca, and waxy appearance 
of the skin. 

The general prostration attending severe rickets diminishes 
the resisting power and opens the way to any infection that 
may be prevalent, but the disease especially predisposes the 
patient to attacks of bronchial catarrh, diarrhoea, laryngismus 
stridulus, convulsions, and chronic hydrocephalus. These 
intercurrent affections, particularly bronchitis, are responsible 
for the majority of fatal terminations. 

When death is caused by the intensity of the disease alone, 
the patient gradually becomes weaker, loses power of support- 
ing the body, and can scarcely move. The difficulty of 
breathing becomes extreme, the face grows livid, sweating is 
profuse, there is complete anorexia, the flesh melts away, 
greatly exaggerating the prominence of the distended abdo- 
men, and finally the child expires asphyxiated or exhausted. 

When the disease tends to recovery, the symptoms gradu- 
ally improve. As the bones begin to harden, the breathing 



I48 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

becomes less difficult, mental activity returns, and the child 
takes an interest in his surroundings. The sleep is sounder 
and quieter, the appetite increases, the bowels become regular 
and the evacuations more healthy, dentition recommences and 
progresses rapidly, flesh is regained, the muscles resume their 
tone and begin to develop, and the abdomen resumes its 
normal size. Sweating and the tendency to lie cool at night 
are the most stubborn features, but slowly disappear. 

As recovery progresses, the bones become much straighter 
than their previous distortion would lead one to expect, and 
the thickening of the flat bones and the enlargement of 
articulating extremities diminish greatly. The bones become 
very thick and strong, but grow in length slowly and insuffi- 
ciently, and a stunted form is carried into adult life. 

Diagnosis. — Rickets of marked type is readily recognized 
by the profuse sweating, anaemia, loss of flesh, lassitude and 
inertia, muscle weakness, labored respiration, delayed denti- 
tion, and disordered gastro-intestinal functions ; by the en- 
larged, misshapen head, with its square, prominent forehead, 
open, depressed fontanelle and craniotabes ; by the small 
face, beaded ribs, distorted chest, distended abdomen, curved 
limbs, and enlarged, loose joints ; and, when the sitting 
posture is assumed, by the bowing of the spine and falling 
backward of the head. 

It is in cases that develop late — after the end of the second 
year — or in the incipient or mild forms that the diagnosis is 
difficult and most important, for the disease is as easily curable 
in its early stages as it is fatal if neglected. The distinguish- 
ing features are increased perspiration from the head, neck, 
and chest, so that the pillow becomes wet during sleep ; a 
tendency to be restless at night and to kick off the bed-clothes 
and " lie cool " ; delay in the closing of the anterior fontanelle 
until after the sixteenth month ; retarded dentition, the tenth 
or twelfth month passing without the appearance of a tooth ; 



RACHITIS. 149 

beading of the ribs, often only to be detected by palpation ; 
slight enlargement of the wrist and ankle joints ; prominence 
of the abdomen, and late efforts at standing or walking. 
These patients are prone to catarrhs of the bronchial and 
gastro-intestinal mucous membranes ; they may be somewhat 
anaemic, and muscularly weak, but there is often no loss of 
flesh ; in fact, an abundance of flabby flesh is no more proof 
of the absence of rickets than excessive emaciation is of its 
presence. 

The enlarged rachitic head may suggest hydrocephalus. 
In the latter condition the head is more regularly enlarged 
and more globular, the forehead projects markedly, the 
disproportion between the cranium and the face is greater, the 
eyes are deflected downward, the iris partly covered by the 
lower lids, and nystagmus and oscillatory movements are 
present ; the bones of the skull are not thickened, the fonta- 
nelle is more open and bulging, and the sutures are wider and 
not bounded by ridges of thickened bone. When the two 
conditions coexist, the head, and skeleton generally, show the 
features of rickets, the fontanelle is large and projecting, and 
the sutures widely open and fluctuating. 

The inability to stand or walk, depending upon muscle 
weakness and relaxation of the ligaments of the spine and 
about the knee and ankle joints, as encountered in associa- 
tion with bone softening in severe cases of rickets, may be 
mistaken for essential paralysis. The muscles, however, while 
feeble, are not powerless, for the child will move and draw up 
the legs if the soles of the feet be tickled. Again, when the 
loss of muscular tone is extreme, the incapacity is general 
and is not confined to a single group or several groups of 
muscles, while other characteristic symptoms of the disease 
are always present. 

Infantile scurvy is readily differentiated from rickets, by the 
purple, swollen, bleeding gums, the extreme hyperesthesia 



I50 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

and immobility limited to the affected limbs, and by the bone 
swelling being fusiform in shape and seated above the joints. 
The etiology of scurvy is well established, and differs from 
that of rickets ; and the rapid recovery under the employment 
of " fresh " food and fruit-juice is quite distinctive. 

Prognosis. — Rickets is slow in development and in recov- 
ery, and fatal cases run a protracted course unless life is cut 
short by one of the ordinary complications or by some inter- 
current affection, measles and whooping-cough being espe- 
cially dangerous. The type of the disease is determined by 
the intensity and continuance of the etiological factors. 

Cases of the grade ordinarily met with in this country 
recover, with little deformity, when early recognized and 
properly treated. The prognosis is very favorable so long 
as the affection remains simple and the bone softening is 
moderate. The outlook is different when there is marked 
malnutrition and extreme softening of the bones, the danger 
in any given case being measured by the degree of distortion 
of the chest and the character of existent complications. If 
the ribs be much softened and the chest greatly deformed, 
respiration becomes difficult, the blood is poorly aerated, 
oxidation of waste material is incomplete, and there is increased 
impairment of nutrition. The slightest bronchial catarrh adds 
to the difficulty of breathing. As rickety patients are very 
sensitive to changes of temperature, they very readily take 
cold, and a trifling attack of bronchitis under these conditions 
often leads to fatal collapse of the lungs. The gravity of the 
bronchial complication is in direct proportion to the degree of 
recession of the thoracic walls during the inspiratory act. 

Of the other complications, diarrhoea is the most serious. 
Convulsions in the rachitic are not, in themselves, especially 
dangerous, but cases in which they have been severe and 
repeated are apt to drift later into epilepsy. Laryngismus 
stridulus is but rarely a cause of death, and the occurrence 



RACHITIS. I 5 I 

of hydrocephalus is of minor importance. Enlargement of 
the spleen, liver, and lymphatic glands, while indicating a con- 
dition of grave cachexia, does not warrant a fatal prognosis. 

Exclusive of stunting of the frame, the health of a child 
who has passed through even a severe attack of rickets may 
be as perfect as if he had never had the disease, unless marked 
deformity of the chest has become set during the stage of 
bone hardening. Then, the consequent impairment of the 
respiratory function produces anaemia and arrests develop- 
ment, and the child is feeble and subject to bronchitis or 
pneumonia, and may become tuberculous. 

Treatment. — As rickets can be readily prevented, atten- 
tion must be paid to this branch of treatment if the disease 
has appeared in former children of the family. The mother 
should avoid all influences which impair the general vigor, 
especially during the period of gestation. She should live in 
healthful surroundings — the country, if possible ; should eat 
easily digestible and nutritious food, meats, sound milk, fresh 
vegetables ; retire early to bed and secure plenty of sleep, 
and in every way lead a quiet regular life, taking sufficient 
exercise in the open air to insure a good appetite and main- 
tain as perfect a condition of health as possible. After birth, 
the infant should be fed from the mother's breast if the milk, 
on analysis, is found to be normal in composition ; otherwise, 
a good wet-nurse, or, preferably, artificial feeding, may be 
employed. 

In artificial feeding a home-modified cows' milk mix- 
ture, with the fat, proteids, and milk sugar properly pro- 
portioned to the age of the infant, is to be selected. The 
use of a small quantity of properly prepared farinaceous 
material for its mechanical attenuant action is often useful, 
but the farinaceae in bulk, the proprietary foods, and con- 
densed milk, except as a temporary substitute, are to be 
strictly avoided, as they are all deficient in fat, the ingredient 



152 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

of the diet most essential to the prevention of rickets. Pre- 
mature weaning from a good breast is to be forbidden, as well 
as prolonged nursing after the mother's milk has become thin 
and poor. Should the time for weaning — the tenth month 
ordinarily — transpire at the beginning of summer, the child 
must be carried through the hot season by mixed feeding, 
the mother's milk being supplemented by two or three bottles 
of carefully prepared artificial food. 

In addition to proper feeding, absolute cleanliness, warm 
clothing, sunlight, fresh air, regularly heated chambers, and 
sanitary surroundings are essential. Infants predisposed to 
rickets are best reared in the country, but in America it is 
possible for those obliged to live in cities, even the poor, if 
they will take the trouble, to keep their babies clean and 
comfortably clad, and to obtain for them open air, sunlight, 
and milk food. 

During the actual presence and progress of rickets the same 
general hygienic measures must be enforced and due atten- 
tion paid the feeding. The following is a suitable diet for 
an infant at the age of eighteen months when the disease is 
uncomplicated by diarrhoea : 

First meal, 7.30 a. m. — A breakfast -cupful (fgviij) of milk, 
with a tablespoonful (f§ss) of cream ; on alternate days the 
yelk of a soft-boiled egg, with a little butter, salt, and bread- 
crumbs, and two to four tablespoonfuls of well-cooked and 
strained cracked-wheat porridge with cream and salt. 

Second meal, 1 1 a. m. — A breakfast-cupful (f Sviij) of milk, 
with a tablespoonful (f§ss) of cream and a slice of whole- 
wheat bread. 

Third meal, 2 p. m. — A good tablespoonful of well-minced 
and pounded mutton or chicken, with gravy and a little 
crumbled stale bread ; a tablespoonful of puree of spinach or 
stewed celery or asparagus tops or cauliflower-tops ; thin 
bread and butter. 



RACHITIS. 153 

Fourth meal, 6 p. M. — Milk and cream as at first and second 
meals ; thin bread and butter. 

For drink, pure water. 

Avoid excess of farinaceous food. 

Should there be complicating diarrhoea with liquid, offen- 
sive evacuations, a diet containing a minimum quantity of 
casein should be adopted, as : 

First meal, 7 a. m. — Veal broth (*4 lb. of vea l to a pint of 
water) and barley water, equal parts (fgiij — iv). 

Second meal, 10 A. M. — Cream, f§ss ; whey (freshly pre- 
pared), fSyj. 

Third meal, 1 p. m. — Same as first, with chicken broth in 
place of veal broth. 

Fourth meal, 5 p. m. — Same as second. 

Fifth meal, 10 p. M. — Same as first. 

If feeble, one meal at 4 a. m., same as second. 

In extreme cases it may be well to limit the food to raw- 
beef juice in one to three teaspoonful doses ever}- two hours, 
with the following mixture twice each day : 

The yelk of a raw egg ; 

Ten (10) drops of brandy ; 

One (1) teaspoonful cinnamon water; and 

One (i) coffeespoonful white sugar, well beaten up. 

While on raw-beef juice the patient must take from 12 to 
24 fluidounces of pure water, barley water, or white-of-egg 
water each twenty-four hours ; these must be given in small 
doses at short intervals. 

Milk feeding; must be resumed o-raduallv after this restricted 
feeding, and partially peptonized milk food is the best inter- 
mediate diet. 

In feeding rachitic subjects it must never be forgotten that 
if there be marked debility, the strength of the food must be 
proportionately weakened without regard to the age of the 
patient ; for the digestion takes its tone from the systemic con- 



154 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

dition, and the feebler, the more nearly does the digestive 
power approach that of the newly born. 

Fresh air is an essential in the successful management of 
the disease. The living rooms must be light and well venti- 
lated, and if the child be too ill to be taken out of doors, he 
should be well wrapped up and placed in his bed near an open 
window, out of a draught and in the sunlight, for an hour or 
more every day. If well enough, the patient must be taken 
into the open air regularly, the duration of the outing being 
lengthened as strength increases. This routine should only 
be interrupted by extreme cold or storms, but in winter the 
abdomen must be covered and supported by a flannel binder, 
the limbs and body protected by woolen underclothing, and 
the feet warmly shod. If the means permit, great benefit will 
be derived from a change of air, from the city to the country 
or to a seashore resort where the air is dry and bracing. 

Cleanliness must be strictly enforced. The patient's whole 
body should be thoroughly sponged each morning with soap 
and warm water, and each evening with warm water alone ; or 
tepid salt and water (§ss sea-salt to Oij water) may be. used 
with advantage, especially over the back and loins. After the 
morning bath the child should be placed prone on the bed, 
and the whole back, from the neck to the buttocks, gently 
rubbed for ten minutes with the open hand. A five minutes' 
inunction of the surface with warm olive-oil twice daily after 
the spongings is also very useful. 

The mattress and bed coverings must be removed from the 
sleeping room every morning and well aired, and the sheets 
must be renewed frequently. 

When the bone softening is sufficient to threaten deformity, 
standing and walking must be prevented as much as possible 
until recovery is under way and the bones harden. In graver 
cases the patient must be confined to bed, and lie upon an 
even, soft mattress ; and light, carefully padded splints, long 



RACHITIS. 155 

enough to extend well below the extremity of the limbs, may 
sometimes be applied. If there be craniotabes, the pillow 
should be soft and care should be taken that the yielding 
parts of the cranium are not subjected to undue pressure. 

The first step in the medicinal treatment is to aid in the 
restoration of normal nutrition by correcting any disordered 
condition of the gastro-intestinal canal. Diarrhoea, with the 
expulsion of mucus and offensive faecal matter, being ordi- 
narily present, it is well to begin the treatment by clearing 
out the alimentary tract by a mild cathartic, such as one or 
two teaspoonfuls of castor oil guarded by 10 drops of pare- 
goric, or by a teaspoonful of spiced syrup of rhubarb combined 
with half a teaspoonful of Husband's magnesia. This is fol- 
lowed by a digestant and astringent, as : 

Uc . Bismuth, subcarb. , 3 i j 

Phenolated essence of pepsin, f ^ iij 

Syr. acacice, f^j 

Elix. aromat, q. s. ad f 5 iij. M. 

Sig. — One teaspoonful every two hours (for a child of one year), interval to 
be increased as diarrhoea improves. 

When there is constipation, the bowels should first be 
unloaded by a mild course of calomel and soda (gr. ss calomel, 
gr. vj sod. bicarb., in divided doses) and regularity maintained 
by one or two teaspoonfuls of milk of magnesia from once to 
three times daily, given with the milk food, or by small doses 
of resin of podophyllum (gr. -^ to y 1 ^) in alcoholic solution. 

Flagging appetite and general tone may be increased by 
tincture of nux vomica in doses of one to two drops three 
times daily ; this may be given with the bismuth mixture, or 
when the diarrhoea is relieved, and in other cases, in the fol- 
lowing prescription : 

r£ . Tr. nucis vom., n\xxiv 

Essence of pepsin, f^iv 

Elix. aromat., q. s. ad f 3 iij. M. 

Sig. — Teaspoonful three times daily before food (for a child of one year). 



156 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Should head sweating require attention, one or two drops 
of tincture of belladonna may be added to this mixture. 

Cod-liver oil is the most successful remedy in rickets, being 
almost a specific, and producing rapid improvement when well 
borne by the stomach, and assimilated. It may be adminis- 
tered pure, or, more efficiently, in combination with lactophos- 
phate of lime in the form of a fifty per cent, emulsion. The 
oil should be given three times daily, directly after food ; for 
an infant of one year, twenty drops to one teaspoonful of pure 
oil, or one to two teaspoonfuls of the emulsion, are sufficient. 
The initial doses must be small until the toleration is estimated, 
and during the course of treatment the faecal evacuations 
should be occasionally examined ; a marked fishy odor or the 
appearance of drops of oil indicating that the doses are too 
large. 

Phosphorus is another useful drug, particularly in cases 
where the disease begins toward the end of the second year. 
It must be employed in minute doses, gr. ^-^ to T ^, accord- 
ing to the age of the patient, and administered three times 
daily, after taking food. It may be prescribed as oleum phos- 
phoratum or in the form known as " Thompson's mixture." 

The former is : 

Take of: 

Phosphorus, I part 

Ether, 9 parts 

Almond oil, 90 parts. M. 

Each minim contains T ^ 7 of a grain of phosphorus. 



The formula for Thompson's mixture is : 

R. Phosphori, gr. j 

Alcoholis (absolut.), traced 

Spt. menth. pip., ttV* 

Glycerini, f^ij. M. 

Ten minims contain T \^ of a grain, and thirteen minims T ^ - of a grain. The 
dose for a child of two years is six minims, thrice daily. 



RACHITIS. 157 

Alcoholic stimulants are often required in severe rickets. 
Brandy" or whiskey is to be selected, and should be given well 
diluted and in doses and at intervals suited to the age of the 
patient and the depth of the prostration. 

Of the complications, bronchitis requires the most active 
treatment. At the first indication of catarrh, maintained 
counterirritation of the thoracic surface must be instituted ; 
this may be accomplished by the constant, careful application 
of hot poultices composed of one part mustard and five parts 
flaxseed meal, or, better, by the following ointment, as it does 
not require such frequent changing, and thereby lessens the 
risk of chilling : 

Take of : 

Oil of turpentine, I oz. 

Olive oil, 1 , 

V each 4 ozs. 

Mutton suet, ) 

Mix without heating. 

This is to be thickly spread on two pieces of flannel cut in 
the shape of ordinary chest protectors, one for the front, the 
other for the back of the chest, and the whole surrounded and 
held in position by a broad flannel roller ; the dressing should 
be renewed twice daily, the original flannel being used. At 
the same time, such relaxants as liquor potassii citratis should 
be employed to produce, as rapidly as possible, free, liquid 
secretion from the bronchial mucous membrane. When the 
cough has become quite loose, aromatic spirit of ammonia, in 
appropriate doses, may be added to the potash solution, or 
the patient may be put upon simple mixtures containing chlo- 
ride or carbonate of ammonium. 

Emetics, syrup or wine of ipecacuanha, are occasionally 
indicated, when there is lividity of the lips, greatly embarrassed 
breathing, and an excessive accumulation of mucus in the 
bronchial tubes. 

Diarrhoea has been already referred to, and requires the 



158 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

same dietetic and medicinal treatment as when it occurs as a 
distinct disorder. 

Convulsions demand the administration of the bromides 
and chloral, and laryngismus stridulus the same drugs, with 
the application of a hot-water compress to the throat during 
the presence of the actual paroxysms. 

In the treatment of rickets the point to be emphasized is 
that drugs are without avail in restoring health if the essen- 
tial dietetic and hygienic measures be neglected. 



CHAPTER IV 



LITH^MIA. 



Lithaemia is a term employed to designate an abnormal con- 
dition of the system, characterized by variously grouped symp- 
toms, and depending upon the presence in the blood of an 
excess of uric or lithic acid, and other alloxuric substances, as 
xanthin, hypoxanthin, heteroxanthin, and paraxanthin. 

While the clinician searches the urine for uric acid, lithates, 
and other imperfectly oxidized products of nitrogenous waste 
as proof of the existence of this disorder, lithaemia is not caused 
by any morbid condition of the kidneys, but depends upon a 
temporary or persistent functional derangement of the liver, 
leading to imperfect metamorphosis of albuminoids absorbed 
from the food into the blood, with the production of insoluble 
uric acid, instead of soluble urea. 

This incomplete oxidation may be due, on the one hand, 
to some innate want of power, often inherited, in the liver, in 
consequence of which its healthy functions are deranged by 
food in quantities and of a quality ordinarily easily digested ; 
on the other, to the supply of aliment being so abundant and 
rich in proteids that the organ is overburdened, and cannot 
fulfil its whole duty. 

Uric acid and its associate products are excreted by the 
kidneys, the skin, and the mucous membrane of the intestinal 
canal, the kidneys taking the greater share of the work. 
The waste materials are taken from the blood by the kidney 
cells and passed into the urine, so that an excess of uric acid 
in the latter fluid demonstrates that it pre-existed in a pro- 
portionate excess in the blood. 

i59 



l60 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

It is quite common for healthy children, after a surfeit of 
food, to void urine laden with uric acid ; this also occurs in 
attacks of acute indigestion and of affections attended by 
pyrexia, but the patient cannot be classed as lithsemic, unless 
the condition be persistent and attended by definite symp- 
toms. 

Etiology. — The manifestations of lithsemia may appear at 
any period of infancy or childhood, and are not confined to 
either sex. Cases are most numerous among the well-to-do, 
partly because the supply of food is apt to be better and 
stronger in proteids, but chiefly on account of inheritance, a 
gouty parentage or ancestry being traceable in the great 
majority of instances. 

Season has a decided influence upon the disease, " lithaemic 
attacks" being much more frequent and severe in winter than 
in summer. This is readily explained by the fact that perspi- 
ration is much increased in hot weather, and the skin, being 
active, assumes a fair proportion of the work of elimination 
which in winter must be mainly done by the kidneys and in- 
testines. 

Insufficient exercise and too much confinement in-doors, 
particularly when combined with a too abundant supply of 
albuminoids, are important factors, complete oxidation of 
waste material requiring a due amount of muscular exercise 
and exposure to sunlight and fresh air. 

The first manifestations of lithsemia are sometimes observed 
after certain of the exanthemata, as measles or other acute 
affection attended by marked gastro-intestinal disturbance, 
especially epidemic influenza. As a temporary condition it is 
a common associate of all febrile attacks. 

Symptoms. — A number of cases are encountered in prac- 
tice in which the excessive formation of uric acid and its anal- 
ogues gives rise to a condition of general ill health ; these 
patients are, as a rule, somewhat advanced in childhood, four 



LITH/EMIA. l6l 

years old and upward, and are nearly always the offspring of 
more or less gouty parents. The child may be well nourished, 
or, at the worst, is a trifle thin and flabby ; the skin is dry, 
pale or sallow, and shows, especially on the face about the 
mouth, circumscribed, dry scaly patches, or there maybe more 
general and marked eczema, or outbreaks of urticaria. 

Mental activity is decided, but there is irritability, uncer- 
tainty of temper, a want of fixedness of purpose, and a tendency 
to tire readily on sustained mental or physical effort. Sleep 
is restless and the patient wakes in the morning unrefreshed 
and heavy-eyed, and, if old enough to describe sensations, com- 
plains of fullness or pain in the head, which passes away while 
the toilet is being made. Sleep may be disturbed by bad 
dreams, or by the peculiar sensation of discomfort in the legs 
known as "growing pains." 

The tongue is lightly coated, flabby, and marked along its 
edges by the teeth ; the appetite is fanciful, sweets and highly 
seasoned dishes being preferred to plain, wholesome food ; 
there is moderate flatulent distention of the abdomen and pain 
in the umbilical region, most marked between meals and often 
relieved by taking food ; the bowels are inclined to consti- 
pation and the evacuations are lumpy, hard, and not uniform, 
clay-colored and deep brown masses of faeces being mingled 
in the same action. 

At intervals, showing some tendency to periodicity, and 
apparently without exciting cause, the regular course is inter- 
rupted by attacks of acute digestive disturbance, in which there 
is nausea, vomiting, increased pain and fever, with a laden 
tongue, fetid breath, and ill-smelling evacuations from the 
bowels. The abdomen is often moderately distended and 
tender to the touch, and some care may be required to ex- 
clude a diagnosis of appendicitis. 

The mucous membranes of the bronchial tubes and pharynx 
are very susceptible to catarrhal inflammation, the tonsils often 
14 



1 62 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

become enlarged, and the child complains of aching in the 
throat and sharp pain on swallowing ; these attacks are of 
short duration, and follow indiscretions in diet more frequently 
than exposure to cold. 

The urine is acid in reaction, high-colored, deposits on 
standing an abundant sediment of pink or brick-red crystals of 
uric acid, and is often voided involuntarily during the hours of 
sleep. 

This group of symptoms is always more marked, and in the 
great majority of cases is only present, during the winter 
months ; the exercise and out-of-door life incident to the 
summer season, and the activity of the skin, produced by hot 
weather, favoring perfect oxidation and free elimination. 

The features of lithsemia, however, may be more specialized, 
affecting one set of organs or one system. 

At times newly born infants eliminate an excess of urates 
during the first few days of life, and uric acid crystals may be 
precipitated in the tubules of the kidneys, producing great 
pain and irritation. Such cases have a lithaemic family history. 
There are frequently repeated straining efforts at urination, but 
the excretion is voided only at long intervals, — once in twenty- 
four hours, for instance, — the quantity is small, may be tinged 
with blood, and leaves a deposit like fine pink sand on the 
napkin. There is severe and protracted crying and evidently 
great pain, increased thirst, frequent pulse, dry skin, and a 
temperature ranging from 102 to 104 F. When, after sev- 
eral days, free secretion is established, the symptoms rapidly 
subside, the patient becomes cool and placid, and large quan- 
tities of uric-acid laden urine are voided. The uric acid in- 
farctions may be the origin of renal calculi, or, being washed 
from the tubules of the kidneys into the bladder, may form 
the nuclei of vesical calculi. 

As such infants become older they frequently suffer from 
attacks of painful micturition. During these the urine is voided 



L1TH.EMIA. 163 

infrequently, the act being instinctively postponed as long as 
possible on account of the pain it causes ; there is fever, rest- 
lessness, and fretfulness, which increase as the time approaches 
when the bladder must be emptied, and during and after 
expulsion there is violent crying. The urine is high-colored, 
acid, contains an excess of urates and oxalates, and is often 
so irritating that it produces vulvo-vaginal inflammation in the 
female and severe irritation of the urethra in the male. This 
quality also produces irritability of the neck of the bladder, 
and if associated, as it often is, with an unstable condition of 
the nerve centres of the spinal cord, leads to nocturnal incon- 
tinence of urine. 

The gastro-intestinal form of lithsemia is probably indepen- 
dent of excessive uric acid formation, being due to auto-in- 
toxication by other alloxuric substances. The condition is 
characterized by a series of well-defined, self-limited paroxysms 
of violent digestive disturbance, which occur at intervals 
varying from one or two weeks to several months, and may 
arise in both infants and older children having a gouty 
ancestry. Without any apparent exciting cause, the attacks 
begin suddenly, with nausea, vomiting, abdominal pain, and 
fever. The breath is offensive, having a sweet ethereal odor ; 
there is total absence of appetite ; everything, even the 
simplest liquid, forced into the stomach is rejected, and occa- 
sionally, when there is excessive retching, blood is vomited ; 
the bowels are sluggish, with putrid, sometimes oily evacua- 
tions ; there is pain and tenderness, usually moderate, but 
sometimes very severe, in the epigastric or umbilical regions. 
The temperature is elevated, ranging about 102 F. generally, 
but at times running as high as 104 or 105 ° ; the pulse is 
frequent and feeble ; the breathing is markedly hurried and 
difficult, though no abnormal physical signs can be detected 
on examination of the lungs ; and there is progressive pros- 
tration and rapid emaciation. After a period of from three to 



164 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

seven days the vomiting stops almost as suddenly as it began, 
and the patient passes into a slow convalescence, abdominal 
tenderness and the evidences of irritation of the stomach and 
bowels remaining for some days. 

As age advances the type of the attacks may change ; 
instead of the obstinate vomiting, fever, and dyspnoea, there 
is violent headache, attended by nausea and followed by pro- 
longed and profound sleep, from which the patient wakes 
improved and refreshed ; in other words, the attacks assume 
the characteristics of migraine. 

The urine voided during a lithsemic attack is diminished in 
quantity, very acid in reaction, high-colored, increased in 
specific gravity, and on standing deposits uric acid and urates 
in the form of fine red or pink particles. In that passed after 
the paroxysm is over, the poisonous xanthin bodies, para- 
xanthin and heteroxanthin, are, according to Rachford,* 
found in enormous excess of the normal quantities existing in 
the urine of non-lithaemic subjects. 

Albumin is sometimes present in the urine, both during 
and after the attacks ; it is usually transient, but is an evidence 
of irritation of the kidneys and an indication for care lest these 
organs become permanently diseased. 

In the intervals between the attacks the patients may be 
perfectly well, though more frequently they are pale, fretful, 
and ailing, and present the general symptoms already detailed. 

While a nervous element runs through all the acute mani- 
festations of lithaemia and lies at the foundation of the ob- 
stinate vomiting, the dyspnoea and the migraine, with its deep 
sleep of auto-intoxication, the condition may also give rise to 
recurrent convulsions, which may be sufficiently long con- 
tinued to develop into the migrainous type of epilepsy. 

Migraine usually appears after infancy, and may, as already 

* il American Text-book of the Diseases of Children." 



LITH^MIA. 165 

indicated, take the place of the storms of acute gastrointes- 
tinal disturbance. It occurs at more or less regular intervals 
in self-limited paroxysms which ordinarily cannot be traced to 
an excitant cause. The pain is unilateral, is often attended 
by disorder of vision, and may or may not be associated with 
nausea, vomiting, and abdominal pain, so that there are two 
distinct forms, one nervous sick-headache, the other migrain- 
ous neuralgia. The paroxysms end in a prolonged toxaemic 
sleep, from which the patient wakes free from pain, but pale 
and languid, until health is restored by a day of rest and a 
night of normal sleep. 

On the skin, lithsemia manifests itself by several forms of 
eruption. Eczema occurs in patches and as a passing symp- 
tom in many cases of the disorder ; but, as an extended and 
continued cutaneous affection, appears most frequently in 
infancy ; in fact, many instances of eczema in early life are due, 
as can be determined by the family history and by examination 
of the urine, to lithsemia, and are best relieved by a diet and 
treatment directed to the prevention of the excessive formation 
of uric acid. 

Urticaria is frequently observed, either in the form of or- 
dinary nettle-rash or hives, characterized by evanescent efflo- 
rescences termed wheals, or as lichen urticatus, in which, 
after the wheals have disappeared, white or red papules appear, 
more or less discretely scattered over the surface. Both forms 
are attended by a sensation of burning and by intense itching ; 
the latter is worse at night, when the child is warmly covered 
in bed, and the consequent scratching produces various 
excoriated and crusted lesions of the skin. 

The occurrence of what, for the want of a better term, may 
be called a roseolous rash is not uncommon in lithaemia. 
This rash is preceded for several days by gastro-intestinal 
disturbance, appears first upon the face and neck, and gradu- 
ally sweeps over the whole surface of the body, occupying 



1 66 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

one, two, or even three days in the transit and fading on the 
old as new localities are involved. The eruption is frequently 
attended by considerable itching, and consists of irregularly 
circular, rather large clusters of red or deep rose-colored 
macules or slightly raised papules, separated by areas of 
normal skin ; it has a superficial resemblance to measles, more 
rarely to scarlatina, and is probably often mistaken for rubella. 
Before efflorescence there may be a febrile elevation of one or 
two degrees, and the cardiac action is moderately increased in 
frequency, but the temperature and pulse become normal as 
the rash appears. The tongue is lightly coated, there is loss 
of appetite, and the bowels are constipated, as a rule, though 
there is sometimes diarrhoea. The urine is high-colored and 
laden with urates. There are no catarrhal symptoms and no 
sore throat ; indeed, the patient has little to complain of, and 
after the course is run, a period of from three to five days, 
rises from his bed without weakness or other sequel. 

Diagnosis. — Given a distinct family history of gout, and 
the decided alterations in the condition of the urine, there 
should be little difficulty in recognizing the form of lithaemia 
attended by general disturbance of the system, with its 
disordered digestion, localized patches of eczema, nocturnal 
incontinence of urine and bone pains, and its development in 
quick-witted, bright-faced children, having active and irritable 
nervous organizations. 

The gastro-intestinal form is marked, in addition, by the 
periodical, self-limited attacks of obstinate vomiting, abdominal 
pain, fever, and the peculiar dyspnoea without pulmonary 
lesion. 

The migrainous form is readily distinguished. 

Of the skin eruptions, the roseolous rash alone presents 
difficulties in diagnosis. This may be mistaken for measles, 
scarlet fever, or rubella. 

The distinctions from measles are the absence of a pre- 



LITH.EMIA. 167 

monitory catarrhal stage, of Koplik's spots, and of an erup- 
tion upon the mucous membrane of the soft palate ; the minor 
degree and the less regular course of the temperature range ; 
the lighter and more distinctly rosy color of the rash and its 
less papular character. 

In scarlet fever the sudden onset, preceded, as a rule, 
by vomiting ; the high fever ; rapid pulse ; the strawberry 
tongue ; the reddened throat with swollen tonsils and enlarged 
submaxillary glands, and the scarlet color and distinctly 
maculated character of the rash, are the distinguishing 
features. At the same time, certain very mild cases of 
scarlatina will tax the skill of the diagnostician to positively 
exclude the lithaemic rash. 

In the absence of an epidemic, it is often very difficult to 
establish the diagnosis of rubella, and it is probable that many 
supposed isolated cases of the exanthem are in reality 
lithaemic. However, rubella often shows some prodromal 
symptoms — malaise, irritability, pain in the limbs, moderate 
suffusion of the conjunctivae, lachrymation, coryza, hoarse- 
ness, sore throat, slight cough, and sometimes, though by no 
means regularly, a rise of from i° to 3 in the temperature. 
The rash appears behind the ears and on the face, and extends 
rapidly over the surface of the body ; it consists of maculo- 
papules, pale rose in color, and varying in size from a pin's 
head to a split pea. When the papules are discrete and large, 
the eruption resembles that of measles ; when confluent and 
small, it is very like scarlatina. 

The average duration of the rash of rubella is three or four 
days, during which the symptoms noted in the prodromal stage 
continue, though the temperature, if elevated, declines after 
the second day ; as the rash fades, brownish or yellowish 
discolorations are left, and there is often a trifling furfuraceous 
desquamation. 

With such meagre points of distinction, it is always well, 



1 68 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

before asserting the presence of rubella, to remember the 
possibility of a very similar lithaemic rash, and to look into the 
previous history of the case and carefully examine the urine. 

Little reliance is to be placed on swelling of the post- 
cervical and post-auricular lymphatic glands as a diagnostic 
feature, as these are enlarged so frequently and from so many 
different conditions in children. 

Prognosis. — As nature's scheme of development, under 
favorable conditions, tends to the physical perfection of adult 
life, and as in children the function of nutrition is so much 
more readily influenced and put upon the right path by 
proper feeding and hygiene, the prognosis of lithaemia is 
much more favorable in the young than in adults, who have 
attained their prime and are, so to speak, set and functionally 
unalterable. 

The grade of the condition giving rise to general symptoms 
and to skin eruptions can be eradicated in time (two to five 
years) by careful attention to the child's diet and mode of life, 
with the assistance of judiciously selected drugs. 

The paroxysms of vomiting in the gastro-intestinal form 
are usually free from risk to life in themselves, though by the 
prostration produced they open the way for intercurrent 
diseases and make them more dangerous. They are entirely 
uninfluenced by medicines, but by properly directed treatment 
in the intervals the attacks gradually grow less frequent and 
severe, and finally cease altogether. 

The nervous forms are still more obstinate, convulsions, if 
often repeated, ending in epilepsy, and migraine frequently 
being a source of life-long suffering to the gouty. 

Treatment. — Little can be accomplished in the relief of 
lithaemia without careful regulation of the diet. 

In breast-fed infants this is difficult to accomplish, but the 
milk must be analyzed, and any abnormal condition corrected, 
as far as possible, by attention to the mother's feeding, exer- 



LITH.EMIA. 169 

cise, and general hygiene, and by the employment in her case 
of an antilithic treatment. 

When the feeding is artificial, a home-modified cows' milk 
mixture of proper average composition for the case in hand 
should be employed, and variations made in the proportion 
of cream and milk as the symptoms demand. Poland water, 
as it increases the activity of the kidneys, is a better diluent 
than plain water, and if the digestion will not permit of the 
addition of sufficient cream to maintain a free action of the 
bowels, from one to five grains of phosphate of sodium may 
be added to each bottle of food. 

For children of four years, a suitable diet is : 

First meal, 8 A. M. — Milk, 7 fluidounces ; Vichy water, 1 
fluidounce (one or two portions); one or two yelks of soft- 
boiled eggs with salt, or a bit of fresh fish or sweetbread ; or 
one or two slices of bran or whole-wheat bread, dry. 

Second meal, 1.30 p. m. — A teacupful of clear meat broth ; 
a bit of chicken, turkey, wild fowl, or fish ; one well-cooked 
green vegetable — i. e., spinach, celery, young onions, cauli- 
flower ; one or two slices of dry bran or whole-wheat bread ; 
junket or rice-and-milk pudding ; cooked fruit with very little 
sugar. 

Third meal, 6.30 p. m. — Milk as at first meal ; sweetbread or 
milk-toast ; dry bran or whole-wheat bread. 

For drink, Poland water or Vichy (domestic); use either 
freely. 

Avoid fats, starches, sweets, raw fruits, and red meats — i. e., 
beef or mutton. 

In still older patients, ten years and upward, a wider range 
is permissible, and the meals may be selected from the follow- 
ing list, which gives the foods allowed as well as those to be 
avoided : 
Breakfast : 

Milk, salted, if desired ; weak cocoa with very little sugar. 



I70 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Bran bread ; whole-wheat bread ; dry toast ; zwiebach. 

Oatmeal or cracked wheat porridge, well cooked, with salt 
and milk. 

Eggs, yelk of soft-boiled or poached ; French omelette. 

Chicken broiled. 

Fresh fish : rockfish, perch, bass (no oily fish). 
Dinner : 

Oysters (in season). 

Clear soup. 

Beef, mutton, or lamb ; poultry or game, small quantity 
(roasted or broiled, and one kind only). 

Two green vegetables : spinach, celery, peas, string beans, 
cauliflower, onions, turnips, vegetable marrow, okra, parsnips, 
carrots, egg-plant, tomatoes raw or baked. 

Rice, hominy, or macaroni (cooked plain). 

Bread as above. 

Light pudding ; apples baked with very little sugar ; stewed 
apples ; stewed prunes ; grapes in moderation, melons. 
Snpper : 

Milk or cocoa, as at breakfast. 

Bread as above ; toast or zwiebach. 

Chicken or game (roasted or broiled); oysters (in season) 
stewed or roasted. Fresh fish ; sweetbread, stewed. 

One green vegetable, as above. 

Cooked fruit, with very little sugar. 

Lithia water to be taken freely. 

No food between meals. Supper two hours before retiring 
for the night. If much sugar is demanded with food, saxin 
to be employed as a substitute. 
Articles to be avoided : 

Cream. White of egg ; eggs cooked with milk. Crabs, 
lobster; salmon and all rich oily fish. Veal ; pork ; ham ; dried, 
smoked or pickled meats of all sorts ; twice cooked meats. All 



lithjEMia. 171 

fried food. Pastry ; cake ; hot bread or rolls ; prunes ; confec- 
tionery of all sorts ; jams ; jellies. Rhubarb ; beets ; cabbage ; 
old peas ; old beans ; potatoes (white or sweet) ; asparagus ; 
radishes ; all raw fruits (except as mentioned above), especially 
strawberries, raspberries, and pears. Fruit cooked with much 
sugar ; dried fruit (figs, dates) ; nuts. Mushrooms. Pickles ; 
vinegar ; spices ; condiments (salt excepted). 

The object of both of the diets given is to allow a minimum 
of albuminous food, to diminish the formation of uric acid and 
its analogues, and a minimum of carbohydrates (sugar and 
starch) to afford the albuminoid waste an opportunity of 
being freely oxidized. From the two lists it is not difficult to 
formulate a diet for intervening ages. 

During the obstinate vomiting of the gastro-intestinal form, 
everything taken into the stomach may be rejected ; still the 
prostration caused by the attack is diminished if the patient 
be forced to take one or two teaspoonfuls of raw-beef juice at 
regular periods, — every two hours, for example, — with sips 
of water, or, better, white-of-egg water in the intervals. At 
the same time, rectal injections of peptonized milk or broth 
must be administered. These enemata should not exceed in 
quantity two fluidounces at the age of three years, should be 
given at a temperature of 98 ° F., and at intervals of four 
hours ; and once daily the rectum must be washed clean with 
warm normal saline solution (one teaspoonful of table-salt to 
each pint of water). 

In addition to careful feeding, the child must live in clean, 
light, and well-ventilated rooms, must have plenty of sunlight 
and regular exercise in the open air, care being taken to avoid 
overfatigue and exposure to the extremes of weather. It is 
very important to keep the skin active, by daily sponge baths 
and friction of the surface. The bath should be given in the 
morning, in the following way : Draw into the tub three 
inches of hot water ; let the patient stand in this, to prevent 



172 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

chilling, and rapidly sponge the whole body with water at 
75° F., taking not more than one minute for the operation ; 
then rub the whole surface gently but thoroughly for ten 
minutes with a soft Turkish towel. At night, before going to 
bed, the ten minutes' dry friction should be repeated. In- 
fants may be sponged in the lap with warmer water (85 to 
90 ) and rubbed in the same way. When eczema develops, 
and involves a large extent of surface, sponging should be 
discontinued, and as little water as possible applied to the 
affected skin, the necessary cleansing being done by fresh 
olive-oil on pledgets of cotton. 

The medicines of most value in the lithaemic state are the 
salts of lithia, phosphate of sodium, and the alterative tonics, 
but to be efficient they must be given continuously, brief 
periods of rest being allowed from time to time. At the age 
of four years one to two grains of citrate of lithia, or two to 
three grains of the benzoate, may be ordered three times 
daily ; the citrate may be given dissolved in water, but the 
benzoate, being less agreeable to the taste, is best adminis- 
tered incased in gelatin, if the child be sufficiently advanced 
to swallow a capsule. Phosphate of sodium should be given 
in solution * or capsule, in doses of gr. 5 to 10 three times 
daily. 

Of the alteratives, arsenic and iodine are to be selected, and 
should be given alternately ; thus, one drop of Fowler's solu- 
tion in a teaspoonful of water three times daily after food for 
two weeks, followed by a similar course of syrup of hydri- 
odic acid, in doses of ten to fifteen drops, in water, three 
times daily ; then a return to the arsenic, and so on. 

During the treatment pepsin or pancreatin maybe required 
to assist digestion ; nux vomica may be indicated as a bitter 



* Solutions of phosphate of sodium are now in the market, of which each 
minim represents one grain of the salt. 



LITH/EMIA. 173 

tonic ; saline laxatives, as phosphate of sodium or magnesia, 
may sometimes be necessary ; and occasionally a course of 
calomel, in broken doses, may be demanded. 

The attacks of prolonged vomiting are seldom curtailed by 
medicines ; still, good is sometimes done by a continued course 
of calomel, in doses of gr. -^ with sodii bicarb, gr. J^, every 
two hours until a grain of the mercurial is taken, or by hourly 
doses of five to ten drops of brandy in one teaspoonful of lime 
water, and, finally, by minute quantities of creasote, r*i T L with 
sodii bicarb, gr. J^, every second hour. When the attack is 
so protracted and violent as to threaten serious results from 
extreme exhaustion, a small suppository, containing ext. bel- 
ladonnas gr. yL and ext. opii gr. y&, may be administered, to a 
child of four years, every twelve, eight, or six hours, according 
to the urgency of the symptoms. Or if these be quickly ex- 
pelled from the rectum, gr. -^ of morphine sulph., with gr. 
2~q-q of atropine sulph., should be introduced, at twelve-hour 
intervals, hypodermatically. Subcutaneous injections of sul- 
phate of strychnia, in doses of gr. y^ every six hours, may 
be called for in very grave cases. 

The pain of migraine can be safely relieved by the following 
combination : 

R . Phenacetin, gr. iv 

Salophen, gr. vj 

Caffeine citrat., gr. ij . 

M. et ft. chart. No. xij. 

A child of six years should take one powder every hour 
until three are taken, unless relief is obtained before, and the 
same course can be repeated after a period of six or eight 
hours. 

A convulsive seizure must be taken in hand energetically. 
After the force of the attack has been broken by immersion in 
a hot bath, the lower bowel must be emptied by an enema, a 
dose of calomel administered, and a course of bromide of 



174 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

potassium or sodium, either alone or combined with chloral, 
instituted ; these drugs are best given by the mouth, but if this 
be impossible, the rectum must be used. 

Lithaemic eczema requires the ordinary local applications. 
When extended urticaria or a general roseolous rash appears, 
the patient should be put to bed, a free action of the bowels 
secured by a mild saline laxative, a light diet ordered, and a 
simple diuretic, as the solution of citrate of potassium, admin- 
istered in appropriate doses. 

The treatment employed for the relief of vomiting and pain, 
for convulsions, and for the skin affections is merely symp- 
tomatic, and if the patient is to be led to recovery, the gen- 
eral measures detailed for the management of the lithaemic 
condition must be rigorously enforced during the free intervals. 



PART II. 

DISEASES OF THE DIGESTIVE ORGANS 



CHAPTER I. 
AFFECTIONS OF THE MOUTH. 

CATARRHAL STOMATITIS. 

The anatomical lesion in this affection consists of a simple 
hyperemia of the mucous membrane of the mouth, with its 
attendant redness, swelling, and altered secretion. This hyper- 
aemia varies both in extent and degree. Sometimes it is limited 
to small, circumscribed points of the membrane, at others it 
extends over large patches, or involves the entire surface. In 
the latter cases it is most intense ; the mucous glands of the 
lips and cheeks participate, becoming enlarged and prominent, 
and occasionally small herpetic patches appear. 

The disease may be primary or secondary. 

Etiology. — The causes of primary stomatitis are the in- 
gestion of food or drinks which are acrid and irritating or too 
hot ; the presence of decaying teeth ; want of cleanliness or 
too persistent cleansing of the mouth ; the use of certain drugs, 
as mercury, iodine, antimony and arsenic, and, perhaps, the 
influence of bacteria acting mechanically or chemically. The 
secondary form occurs during the course of acute febrile dis- 
eases, as measles, scarlatina, typhoid fever, and in disordered 

i75 



I76 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

conditions of the stomach, particularly those attended by acid 
eructations. Catarrhal stomatitis is also met with in the 
earlier stages of more serious diseases of the mouth. 

While not limited to any special age, the disease occurs 
most commonly during infancy, since at this period several of 
its causes are apt to be simultaneously operative. 

Symptoms. — These are mainly local. The lips are un- 
naturally full and red, and the skin at the angles of the mouth 
and on the chin may be excoriated by the dribbling saliva. 
The oral mucous membrane presents either a punctated, a 
patchy, or a diffuse redness. It is moderately swollen, and 
hot and tender to the touch. At first the mouth is dry, but 
soon the salivary flow is increased, the secretion becoming 
acid in reaction, and sometimes viscid and flocculent. The 
mucous glands of the cheeks and lips may project as yellowish- 
white or transparent nodules, yielding a drop of mucus on 
pressure. Infrequently, too, isolated collections of small vesi- 
cles develop and then quickly dry up, leaving scales behind 
them. The tongue is either red and smooth, with enlarged 
and reddened fungiform papillae, or covered with a white frost- 
ing, through which the papillae project in scarlet points. The 
last condition is most frequently seen when the stomatitis is 
secondary to gastric catarrh. The acts of sucking and eating 
are painful, and resistance is offered to inspection of the mouth. 
Cold drinks are craved. 

Restlessness, irritability, slight heat of skin, anorexia, — de- 
pending chiefly upon the local tenderness, — and constipation 
are the general symptoms of primary catarrhal stomatitis. In 
the secondary variety the general symptoms depend upon, and 
vary with, the originating disease. The local features, how- 
ever, remain the same, with the addition of certain special 
features, as Koplik's spots and maculation of the soft palate in 
measles, and the punctation of the pillars of the fauces in scar- 
latina. 



AFFECTIONS OF THE MOUTH. \JJ 

The course of the disease depends upon the cause and the 
treatment adopted, though it is usually acute, rarely lasting 
longer than a week. 

Treatment. — After attending to the removal of the exciting 
cause, if this be possible, the diet must be regulated. To suck- 
lings, the breast or the carefully prepared bottle alone should 
be allowed, and milk guarded by lime water must constitute 
the food of older children. If the act of sucking be so painful as 
to cause the infant to refuse the breast or bottle, it is necessary 
to give food, temporarily, from a spoon or glass. 

The mouth should be thoroughly but very gently washed, 
at intervals of an hour, while the patient is awake, with a 
solution of sodium borate or sodium salicylate in rose water 
(gr. x to f5j). After taking food, particularly, the mouth 
ought to be cleansed with cool water, and the lotion used. 
A little mass of absorbent cotton twisted around the end of a 
probe, or a soft rag folded around the index finger, is the 
best vehicle for carrying the lotion. In obstinate cases a 
weak solution of nitrate of silver (gr. j— f5j) should be applied 
once daily. 

Regular evacuation of the bowels must be secured by saline 
laxatives. If the skin be hot and dry, liquor potassii citratis, 
in doses of a fluidrachm every two or three hours, for a child 
one year old, is indicated. When the tongue is heavily 
coated, and the stomach disordered, recovery may be much 
hastened by gr. y z of calomel given in broken doses with 
bicarbonate of sodium and followed by a digestant, as : 

& • Sodii bicarbonatis, gr. xxiv 

Pulv. pepsini (Fairchild's), gr. xij 

Pulv. aromatici, gr. iij. 

M. et ft. chart. No. xij. 
SlG. — One powder four times daily, administered in milk or syrup, for a 
child between seven and twelve months old. 



15 



I78 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

APHTHOUS STOMATITIS. 

This is a much more common disease than uncomplicated 
catarrhal stomatitis, and is most frequently met with in chil- 
dren between the ages of six and fifteen months. 

The anatomical lesions are hyperaemia of the mucous 
membrane of the mouth, and the formation of aplithce or 
small, superficial, yellowish-white ulcers. 

Etiology. — Any condition which reduces the general 
strength and interferes with nutrition may exert a causal 
influence. For instance, overcrowding ; residence in damp, 
ill-ventilated houses or rooms ; insufficient food and clothing ; 
various acute affections, as ague, pneumonia and the exanthe- 
mata, and chronic diseases, especially of the digestive tract. 
The direct agent may be bacterial, but it is certainly some, 
and probably a varying, form of deleterious material, circulat- 
ing in the blood, and acting on the nerves in such a way as 
to produce an herpetic eruption upon the mucous membrane 
of the mouth ; the aphthae being undoubtedly herpetic in 
character. 

The exciting agencies are : want of proper attention to the 
cleanliness of the mouth ; foul nursing bottles ; the adminis- 
tration of sour milk, or an excess of farinaceous food. In 
older subjects an indulgence in pastry or candy is often fol- 
lowed by an attack of aphthae, and certain children always 
suffer after eating some particular article of food, as honey, 
walnuts, or salted fish. All these causes are active in the 
production of a catarrhal state of the stomach, which invari- 
ably precedes and attends the disease under consideration. 

The disease is not contagious, but at times a sufficient num- 
ber of cases occur simultaneously to constitute an epidemic. 

Symptoms. — For twenty-four hours prior to the appear- 
ance of aphthae, there is fretfulness, increased thirst, and poor 
appetite. Next, the mouth becomes hot, and a few hours 



AFFECTIONS OF THE MOUTH. I 79 

later the ulcers appear. The lips, swollen and vividly red, are 
held somewhat apart, and clear saliva drops from the mouth, 
excoriating the skin of the lower lip and chin. The oral 
mucous membrane is red, swollen, and hot, and presents the 
characteristic ulcers. These are usually discrete, and make 
their appearance first on the inside of the lower lip and the 
edges of the tongue, though they may, subsequently, extend 
to the cheeks, gums, soft palate, and even the tonsils. Their 
number varies from one to twenty ; and their size, from that 
of a pin's point to a split pea. The ulcers — oval, round, or, 
more rarely, linear in shape — are slightly elevated above the 
surrounding surface, have deeply reddened edges and whitish 
or yellowish-white floors. They are excessively sensitive, and 
thus mechanically interfere with sucking, chewing, speaking, 
or other movement of the mouth. The edges of the tongue 
are clean and red, while its dorsum is covered with a thick, 
white coating. There is often moderate enlargement and 
tenderness of the submaxillary lymph glands. 

Together with these local symptoms, there is restlessness, 
increased pulse rate, elevated surface temperature, dryness of 
the skin, thirst, anorexia, nausea with frequent eructations of 
acid liquid and occasional vomiting, and either constipation or 
diarrhoea. The loss of appetite is due both to the painful 
condition of the mouth and to the disordered state of the 
stomach. 

When all the ulcers appear simultaneously, the disease runs 
its course in from four to seven days. The fibro-cellular 
exudation covering their floors then disappears, leaving the 
mucous membrane beneath intact, but intensely red, though 
occasionally shallow, clean ulcers are left, which quickly heal. 
At the same time the local and constitutional symptoms 
rapidly subside. If, on the contrary, the ulcers develop in 
successive crops, as is sometimes the case, the duration may 
be prolonged for a fortnight or more. 



ISO DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

There is another form of aphthous stomatitis, termed con- 
fluent, in which the aphthae are very numerous, and tend to 
run together, forming large, irregular ulcers. The symptoms 
are proportionately severe. It occurs secondarily to grave 
constitutional diseases — namely, measles, variola, scarlet 
fever, diphtheria, typhoid fever, pneumonia, and whooping- 
cough. 

The diagnosis of the ordinary, discrete form is unattended 
with difficulty. Thrush bears the closest superficial resem- 
blance ; but in this disease the creamy-white spots are slightly 
raised above the surface, being deposits upon the mucous 
membrane. There are no ulcerations, the color of the free 
membrane is rather purplish than scarlet, and finally the 
thrush fungus is discoverable by the microscope. The 
graver, confluent form is distinguished from ulcerative stoma- 
titis by the absence of fetor, and by the different seat and 
appearance of the lesions. The ulcers in the latter disease 
always begin at the margins of the gums, extend rapidly, and 
present grayish floors. 

Aphthous stomatitis is usually a mild disorder, recovery 
taking place quickly and without difficulty. The confluent 
form, besides running a longer course, is more difficult to 
cure, on account of the general debility induced by the asso- 
ciated disease. 

Treatment. — Since some disturbance of digestion is con- 
stantly at the bottom of the local trouble, attention to the 
feeding apparatus and to the diet is of great importance. 
Absolute cleanliness of both bottles and tips must be insisted 
upon, and if a complicated, patent arrangement of rubber and 
glass tubing has been used with the bottle, it must be at once 
discarded and a simple rubber tip substituted. Regular hours 
for meals — the frequency varying with the age of the child — 
are as essential as the selection of suitable food and its 
administration in proper quantities. 



AFFECTIONS OF THE MOUTH. l8l 

A child of six months should be fed every three hours, 
between 6 o'clock in the morning and 9 o'clock in the eve- 
ning. A mixture such as the following — 

Sound milk f 3 iij 

Cream, f^j 

Lime water, f^'j 

Sugar of milk, 3J ; 

may be made immediately before the time of feeding ; poured 
into an absolutely clean bottle, to which a clean tip is fitted, 
and the whole placed in a water-bath and heated to a tempera- 
ture of about 98 ° F. This preparation is easily digested, 
contains enough lime water to prevent rapid and firm clotting 
of the milk, and is not so great in quantity as to overdistend 
the delicate stomach and cause vomiting. 

Children of two years of age and over should be placed on 
a simple diet : a breakfast, luncheon, and supper of stale 
bread and milk guarded by lime water (one part to three) and 
a midday dinner of broth and well-boiled rice. 

The disease usually makes its appearance too long after the 
causative error of diet to be stayed by the administration of 
an emetic. If, however, an overloaded stomach be indicated 
by fever, restlessness, and epigastric pain and distention, a 
dose of the wine or syrup of ipecacuanha* should be given. 
If the bowels be constipated, a gentle laxative is required. 
Probably the best is calomel ; for a child from six to twelve 
months old a powder containing half a grain of the mercurial 
and five grains of sugar may be placed dry upon the tongue 
in the evening, to be followed next morning by a small tea- 
spoonful of magnesia in milk or lemonade. If, on the con- 
trary, there be diarrhoea, the bowels should be first cleared of 
irritating materials by a teaspoonful of castor oil, into which 

* For a child one year old the emetic dose of wine of ipecacuanha is fifteen 
drops ; of the syrup, half a teaspoonful, repeated if necessary. 



152 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

five drops of paregoric have been dropped, and the following 
prescription given : 

R. Sodii bicarbonatis, gr. xxiv 

Syr. rhei aromatici, 

Syrupi, aa f.^ss 

Aq. menthae piperita?, q. s. adf^iij. M. 

Sic. — A teaspoonful every three hours. 

The fever, when very moderate in degree, requires only a 
plentiful supply of cool water to drink, and a hot mustard 
bath in the evening. The strength of the latter should be one 
teaspoonful of strong mustard to as much water as will cover 
the child's legs and hips when in a sitting posture. The 
duration of the bath should be from five to ten minutes. If 
the skin be quite hot and dry, a saline diaphoretic is neces- 
sary. The best is liquor potassii citratis, in doses of one tea- 
spoonful every two hours. Sometimes it is well to add one- 
fourth of a drop of tincture of aconite to each dose of the 
potash solution. 

Locally, the best results will be obtained by lightly touch- 
ing each ulcer with a point of lunar caustic. The pain incident 
to the application may be prevented by the previous applica- 
tion of a 4 per cent, solution of cocaine. In ordinary cases 
one such application suffices ; in severe, it is necessary to 
repeat it daily for a week or more. In addition, the mouth 
must be washed thoroughly and frequently, particularly after 
food is taken, with cool water ; with a solution of permangan- 
ate of potassium, gr. iij— fgj, or of chlorate of potassium, as : 

U . Potassii chloratis, gr. xx 

Vini opii, HVv 

Glycerini, f gj 

Aquae rosae, q. s. ad I5J. M. 

After the fever has subsided, a digestant will be required 
for a few days. Thus, twenty drops of essence of pepsin three 
times daily may be ordered ; or, if there be acidity, with a 



AFFECTIONS OF THE MOUTH. 1 83 

coated tongue, the powder recommended, under the same cir- 
cumstances, in catarrhal stomatitis. 

The local treatment must be persevered in until the ulcers 
have healed and the mucous membrane has returned to its 
normal condition. 

Bednar's Aphtha is the term applied to an ulceration of 
the soft palate or of the mucous membrane covering the hard 
palate. The condition arises in early infancy, and is due to 
rough cleaning of the mouth, or to the friction of an over- 
long or badly shaped bottle tip. The ulcer is irregularly tri- 
angular or Y-shaped, in the latter case being linear and situ- 
ated over the palatine suture and the line of junction of the 
hard and soft palates ; the ulcers are shallow and covered by 
a gray or yellowish coating. 

This form of aphtha yields readily to proper treatment, 
which consists in gentle cleansing of the ulcer with dioxide 
of hydrogen diluted with an equal quantity of water ; the 
daily application of a weak solution of nitrate of silver (gr. 
v— f§j), and the frequent use — every two hours — of a I per 
cent, solution of salicylate of sodium. 



ULCERATIVE STOMATITIS. 

This affection of the mouth is quite common in childhood. 
It is usually seen in children between three and eight years of 
age ; is never met with before the commencement of dentition, 
and is not contagious, though it sometimes occurs in almost 
epidemic profusion. 

The anatomical lesions consist of parenchymatous inflam- 
mation of the pums, and often of the tongue and cheeks, with 
ulcerative destruction of the mucous membrane. The tissue 
destruction may extend to the periosteum and, in extreme 
cases, produce necrosis of the jaw bone. Microscopical 



1 84 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

examination of the floors of the ulcers reveals pus corpuscles, 
isolated blood corpuscles, and granulated cells, embedded in 
an amorphous, finely granular mass which is filled with vari- 
ous bacteria. There is no trace of pseudo-membrane. 

Etiology. — As the disease is not contagious there is prob- 
ably no specific epidemic influence in its causation. When 
groups of cases, large enough to be classified as epidemics, do 
occur, they are generally limited to single houses or institu- 
tions, and may be traced to bad hygienic surroundings affect- 
ing alike all the inmates. Insufficient or bad food and residence 
in unhealthy, cold, damp, ill-ventilated houses constitute one 
set of causes. 

Again, ulcerative stomatitis is very apt to follow in the wake 
of typhoid fever, scarlatina, measles, variola, and dysentery ; 
and since each of these primary diseases usually occurs as an 
epidemic, a similar tendency in the sequelae is readily ex- 
plained. 

A certain amount of reduction of the constitutional vigor 
seems to be an essential precedent to the development of the 
disease. Sickly, rickety, and tuberculous children are suscep- 
tible subjects, and when the gums are loose, soft, and hyper- 
aemic they are more readily affected than when firm and 
closely applied around the teeth. I have, however, seen it 
occur in healthy children. For instance, I lately saw it devel- 
oped in two children of four and seven years, who had returned 
to the city after a summer in the mountains, during which 
there had not been a single day of illness, and, on the whole, 
two more robust specimens of healthy childhood could not 
well be found. The attack seemed to be attributable to the 
opening of a sew r er within a block of their home. 

The presence of decaying teeth, want of cleanliness of the 
mouth, and the careless administration of such medicines as 
mercury, lead, and phosphorus, are exciting causes. 

Symptoms. — At first there is a sense of heat and pain in 



AFFECTIONS OF THE MOUTH. 1 85 

the mouth, and the breath grows offensive in odor. Next the 
gingival mucous membrane, immediately about and between 
the teeth, becomes red and swollen. The swelling rapidly 
increases, the points of the gum between the teeth standing 
out like flasks, and the whole margin becoming so soft and 
tender that it bleeds upon the lightest touch. In the course of 
twenty-four hours the edge of the gum, where it touches the 
teeth, changes from a bright red to a yellow or yellowish-gray 
color, and softens, breaking down into ulcers. 

Ulceration generally commences on the external surface of 
the lower gum, and in the beginning appears as a more or 
less extended, narrow, and indented gray band, following the 
line of the teeth. Later it may appear on the outer surface 
of the upper gum ; on the internal surface of both the lower 
and upper gums ; on the edges of the tongue, at points where 
the organ presses against the teeth ; and finally on the cheeks. 
In the latter position it often happens that the ulceration 
corresponds exactly with that of one or both gingival bor- 
ders, forming a single or double strip running parallel with the 
jaws. 

The ulcers are depressed, have a ragged, dirty gray or 
brownish floor, and intensely red, swollen edges. The mucous 
membrane not involved shows the characteristics of catarrhal 
stomatitis. 

When the disease is fully developed, the lips are tumid and 
red. They are held apart, and a stream of yellowish, some- 
times bloody, always ill-smelling, acid and viscid saliva con- 
stantly drips away, excoriating the skin over which it flows. 
If the mouth be kept closed, as it sometimes is, half an ounce 
or more of this fetid fluid gushes out whenever the lips are 
parted in speaking or in taking food. The submaxillary 
glands and the lymph glands of the neck are moderately en- 
larged, and there is often oedema of the face, limited or gen- 
eral, according to the extent of the ulceration. 



1 86 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

The mouth is the seat of constant burning and pain ; is hot 
and tender to the touch, and chewing causes great suffering. 
Between and upon the teeth there is a deposit of yellow unctu- 
ous material. The tongue, in addition to presenting the mar- 
ginal ulcers, is swollen and heavily coated with a dirty, yel- 
lowish-white fur. The speech is thick ; the breath has a 
characteristic heavy odor ; there is loss of appetite, due prin- 
cipally to the pain produced by chewing and the contact of 
food with the ulcerated mucous membrane ; thirst is moder- 
ately increased ; and the bowels are normal, or inclined to 
constipation. The little sufferer is restless and sleeps badly. 
The pulse is feeble, and there are other evidences of general 
debility, but there is little febrile reaction, the temperature, 
even in well-marked cases, rarely reaching a higher marking 
than 99.5 F. in the evening. 

In severe and protracted attacks the ulcers increase in 
breadth and depth, become covered with a gray or brownish 
pulp, and the teeth, deprived of the support of the gum, grow 
loose and *are easily removed from the alveoli. Sometimes 
the periosteum of the jaw is destroyed, and more or less ex- 
tensive necrosis results. Exceptionally, in very weak and 
badly nourished children the stomatitis runs into actual gan- 
grene or noma. 

The symptoms ordinarily reach their height in from two to 
four days, and, under proper treatment, disappear in as many 
more, the ulcers cleaning off and healing without cicatrization. 
Severe or badly managed cases go from bad to worse for a 
time, and rarely recover under three or four weeks, during 
which the suffering is extreme. Those involving necrosis of 
the jaw, and those terminating in noma, run a still more pro- 
tracted course. 

Diagnosis. — The appearances of the gums before ulceration 
the position in which this process begins, the character of the 
individual ulcers, and the odor of the breath, furnish a train 



AFFECTIONS OF THE MOUTH. 1 87 

of symptoms distinguishing ulcerative stomatitis from any other 
affection of the mouth. 

The prognosis, in the vast majority of instances, is most 
favorable. When necrosis of the jaw occurs, the duration is 
greatly prolonged, but ultimate recovery is the rule. Inter- 
current noma, on the contrary, often leads to the death of the 
child, and, under the best of circumstances, leaves its traces 
in permanent deformity of the face. 

Treatment. — The first step is to improve the sanitary sur- 
roundings of the patient, or, if this be impossible, to remove 
him to healthful quarters. The importance of cleanliness, 
fresh air, and sunlight are not to be lightly estimated. 

The diet should be liquid, but nutritious. Apart from the 
fact that solid food will be refused on account of the pain 
caused by mastication, milk and animal broths are better suited 
to the somewhat enfeebled digestive powers, and should be 
relied upon entirely. Cool water ought to be allowed in suf- 
ficient quantities to satisfy the thirst. 

Of drugs, chlorate of potassium is the most important, since 
it ranks almost as a specific for this disease. It may be given 
alone, simply dissolved in water, or combined with dilute mu- 
riatic acid, as in this prescription : 

R . Potassii chloratis, . gr. xlviij 

Acidi muriatici dil., fsjj 

Syrupi, f^ ss 

Aquas, q. s. ad f^iij. M. 

S. — One teaspoonful, diluted, every two hours, for a child three years old. 

In this combination the chlorate of potassium, being elimin- 
ated by the salivary glands, constantly comes in contact with, 
and acts as an alterative upon, the ulcers. The muriatic acid 
aids digestion, and acts as a tonic. If a more decided tonic 
effect be required, one-fourth to one-half of a grain of sulphate 
of quinine may be added to each dose. 

Chlorate of potassium, too, constitutes the main element of 



1 88 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

the local treatment. Its action is somewhat improved by the 
addition of carbolic acid, as in the following wash : 

R . Potassii chloratis, gr. lxxx 

Acidi carbolici, , gr. ij 

Glycerini, f^j 

Aquae, q. s. ad f^viij. M. 

A bit of absorbent cotton saturated with this wash should 
be thoroughly applied to all the ulcers -at least once in every 
hour ; or, at the same intervals, the child may take a quantity 
into the mouth, move the cheeks and tongue in such a way 
as to bring it in contact with the whole mucous surface, and 
then expel it. Should there be much pain, a four per cent, 
solution of cocaine may be applied to the ulcerated surfaces 
two or three times daily. I have also had good results from 
salicylate of sodium or permanganate of potassium applied as 
a wash at intervals of two hours. 

After the ulcers have healed, the specific treatment may be 
discontinued, and the patient placed upon a simple tonic, as 
ferrated elixir of cinchona, in doses of half a fluidrachm three 
times daily, until the health is perfectly restored. 

As additions to this treatment, iron and stimulants will be 
required in severe and protracted cases. The tincture of the 
chloride is the best form of iron. It should be given in doses 
of three drops (Xiss) every two hours for a child three years 
old, and may be combined very well with the mixture of 
potash, acid, and quinine (p. 187). The best stimulant is 
whiskey, in doses of one-half to one teaspoonful, in milk or 
water, every three or four hours. Indolent ulcers may be 
stimulated to heal by touching them lightly with the solid stick 
of nitrate of silver, the parts being first anaesthetized by cocaine. 
Loosened teeth must always be allowed to remain in position, 
as they often become firm again after the termination of the 
disease. 

When necrosis occurs, no change is necessary in the gen- 



AFFECTIONS OF THE MOUTH. 1 89 

eral plan of treatment. Especial attention, however, must be 
paid to the cleanliness of the mouth, and hot compresses 
should be kept constantly applied to the cheek of the affected 
side. Surgical interference may become necessary. 



GANGRENOUS STOMATITIS— NOMA. 

This affection consists of a rapid gangrenous destruction of 
the cheek and adjacent parts, occasionally beginning on the 
lips, but usually near one corner of the mouth. It is gener- 
ally asymmetrical, the left cheek being attacked in the majority 
of instances, but sometimes both cheeks are simultaneously 
involved. 

Etiology. — Noma is, fortunately, an uncommon disease. 
Sucklings seem to be exempt from it, and most of the cases 
occur between the ages of two and twelve years. Girls are 
more liable to be attacked than boys. It is always of secondary 
origin, following severe maladies, such as measles, typhoid 
fever, gastro-intestinal catarrh, ulcerative stomatitis, scarlet 
fever, smallpox, broncho-pneumonia, tuberculosis, protracted 
intermittent fever, and whooping-cough. This order also rep- 
resents the etiological activity of the diseases mentioned. 
These, then, may be looked upon as predisposing causes ; 
but, despite the presence of any one of them, noma only occurs 
in those children who have been previously weak, ill housed, 
and ill nourished. 

There is no evidence to show that it is contagious, though 
it sometimes occurs as an endemic in overcrowded hospital 
wards and children's homes. These endemics may be ex- 
plained in the same way as similar outbreaks of ulcerative 
stomatitis. 

Symptoms. — During convalescence from measles, or other 
of the diseases mentioned, a nodule, from a quarter to half an 
inch in diameter, appears spontaneously upon the child's cheek, 



190 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

in the neighborhood of the corner of the mouth. This can 
be easily detected from the outside, but it is best felt by open- 
ing the mouth and grasping the cheek between the thumb and 
forefinger. It is extremely hard, and very sensitive, especially 
at the periphery. If the case be seen during the first few 
hours, the mucous membrane over the mass will be observed 
to be converted into a flat, ichorous bulla. Usually, however, 
this membrane is found hanging in ragged shreds from a black, 
gangrenous base. The skin over the induration is pale or 
mottled with purple spots, tense and shiny as if oiled. 

After twenty-four hours the investing integument becomes 
bluish, the epidermis scales off, and a black eschar forms. 
This has a tendency to shrink, and in so doing leaves a linear 
depression filled with ichor, which separates it from the healthy 
skin. Notwithstanding this line of demarcation, the tissue 
destruction rapidly extends, both in superficial area and depth. 
Soon the cheek is perforated, and a dirty, stinking, ichorous 
saliva, filled with shreds of broken-down tissue, flows out 
beside the eschar and over the cheek. At the same time the 
lips, chin, and uninvolved portions of the cheek become cede- 
matous, the skin being tight and glistening, and the adjacent 
cervical glands enlarged. 

At the very outset there are few constitutional symptoms. 
The child complains of little or no pain, persists in his amuse- 
ments, has a good appetite, a temperature but slightly above 
the normal, and a pulse but moderately increased in frequency. 
As the eschar forms, the scene changes, symptoms of consti- 
tutional depression setting in. The face is pale and expres- 
sionless on the affected side, the skin cool and dry, though 
rarely there is high fever of the hectic type ; the pulse is feeble 
and frequent — sometimes counting 120 or 140 beats per 
minute — and there is oedema of the feet. The mind is apa- 
thetic, no complaints of pain are made, and at most a sense of 
discomfort is indicated by constant whimpering. The mouth 



AFFECTIONS OF THE MOUTH. 



I9I 



is held partly open, the breath is extremely fetid, the teeth 
and tongue are covered with sordes, and there is an abundant 
flow of bloody or dark-colored saliva. Severe hemorrhage 
never occurs, as the blood-vessels are closed at an early stage. 
The appetite is often retained, the thirst is intense, and the 
bowels are usually relaxed. In spite of the food taken, the 
strength rapidly declines ; sometimes, though, it is wonder- 
fully retained, the patient being able to sit up, and even leave 
his bed, until a few hours prior 
to death. 

The air of the sick-room 
has a characteristic gangrenous 
odor. 

Perforation of the cheek oc- 
curs about the third day of the 
disease, and many cases die at 
this time. Others linger until 
the end of the first or second 
week. 'Under these circum- 
stances the gangrene invades 
the lips as far as the median line, 
the corresponding ala of the 
nose, and the cheek as far as the 
lower eyelids, the tragus, and 
the inferior border of the lower 

jaw. Extending inward, the gums and periosteum of the 
jaws are destroyed ; the bone becomes necrotic, and the teeth 
so loose that they can be readily pushed out by the finger, 
together with pieces of the alveoli. Finally the cheek is cast 
off in large, black sloughs, leaving huge openings, with black, 
ragged, and indurated edges, through which the blackened 
and necrosed bones and loosened teeth can be seen. The 
child's face is then unrecognizable ; the symptoms of consti- 
tutional depression are greatly intensified ; there is subnormal 




Fig. 6.— Gangrenous Stomatitis. 



192 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

temperature, delirium, profuse diarrhoea, purulent and even 
gangrenous infiltration of the lungs, and occasionally, also, 
gangrene of the genitalia, in females. Death is the only 
result to be expected. 

Exceptional cases do recover. In these, the gangrenous 
edges become clean and covered with granulations, the ne- 
crosed bone is thrown off, and, after months, cicatrization 
takes place, with great disfigurement. 

Pathology and Morbid Anatomy. — The fact that noma 
makes its appearance uniformly at one point, on the cheek, 
and is unilateral, suggests a localized causative lesion. The 
most natural theory, that of embolism of a large arterial 
branch, due to weakness of the cardiac muscle or increased 
coagulability of the blood, — effects of the primary disease, — 
is untenable, because, with the given conditions, emboli ought, 
at least occasionally, to be found in other positions, which 
does not happen. It is necessary to look rather to the nerves : 
namely, the trifacial, the facial, or the vaso-motors. That the 
gangrene is due to a lesion of one of these, seems to be 
borne out by experiments. Thus, Magendie found that divi- 
sion of the trifacial in dogs caused destruction of the corre- 
sponding eyeball, and half of the tongue became dry, brown, 
and fissured, the gums spongy and hemorrhagic, and the 
teeth loose. " In animals tenacious of life, the batrachians, 
for example, the soft portions of the face are cast off in shreds, 
just as in spontaneous gangrene. After three or four weeks 
only one-half of the face remains." * 

A variety of bacteria can be found at the seat of lesion, but 
their presence has no etiological significance. The body of 
a child dead from noma has a gangrenous odor and decom- 
poses quickly ; the skin is shriveled, and the face and the feet 
are cedematous. The gangrenous parts are converted into a 

* Vogel, " Ziemssen's Cyclopaedia," vol. VI, p. 812. 



AFFECTIONS OF THE MOUTH. 1 93 

blackish-brown mass, and the maxillary bones are naked, 
brownish in color, and brittle. The nerves, when examined 
microscopically, are yellowish in color but unaltered in struc- 
ture, and the blood-vessels are thickened and rilled with 
thrombi. In the uninvolved parts of the cheek there is a 
dense exudation, while the palate, tongue, and tonsils are 
swollen and covered with black scales and crusts. The lungs 
are the seat of hemorrhagic infarctions, lobular or metastatic 
lobar pneumonia, and sometimes gangrene. The intestines 
are catarrhal. Evidences of the primary disease may also be 
present ; for example, the lesions of typhoid fever or dysen- 
tery. 

Noma of the genitalia, though rare, is occasionally encoun- 
tered. I have seen several cases within the last three years. 
The local appearances and the clinical history as to causation, 
and so on, correspond with what has already been stated. 
The possibility of such an occurrence should be borne in mind 
as a matter of interest. 

Diagnosis. — Noma is readily distinguished from other oral 
affections by its course, its peculiar and almost uniformly 
identical seat, and its well-marked local features. 

Ulcerative stomatitis is the only other of the class at all 
likely to be confounded with it. This begins with ulceration 
of the gingival margin, and when the cheek becomes involved, 
the ulcers situated there are linear in shape and have a gray- 
ish floor. There is no sloughing or gangrene of the mucous 
membrane. The cheek never presents a circumscribed indura- 
tion, being at most simply cedematous. The skin shows no 
tension, unctuous appearance, or discoloration, and perforation 
of the soft parts never occurs. The breath is fetid but not 
gangrenous ; salivation is less, and the saliva, though some- 
times bloody, is not mixed with shreds of gangrenous tissue. 
The course is much less rapid, and the ulcers, while they 
extend in area, retain the same appearances throughout. 



194 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Finally, the general symptoms are distinctive, the results of 
treatment are most satisfactory, and a fatal termination is ex- 
tremely uncommon. 

Malignant pustule closely resembles noma. The former, 
however, always begins oh the exterior, involving the epider- 
mis first and extending through the successive layers of skin 
to the deep structures. 

The prognosis is most unfavorable. Vogel sets the mor- 
tality at 80 to 90 per cent.,* and out of one hundred and two 
cases that came under the observation of Steiner,f only four 
recovered. Death may occur at any time between the third 
and fourteenth day ; a rapid course, however, is very much 
more frequent than the reverse. Even when recovery does 
take place, the patient is permanently disfigured by scars, or 
crippled by the development of ectropion, or of restricted 
movement of the jaw, in consequence of cicatricial contraction, 
or by the loss of teeth and portions of the maxillary bones. 
Such cases also drag through a very protracted convales- 
cence. 

Treatment is most unsatisfactory. Something can be done 
in the way of prophylaxis by a proper management of the 
known predisposing diseases. Secure sound hygiene in the 
sick-room ; give good nourishment, and avoid the abuse of 
mercurials and debilitating treatment generally. 

If, notwithstanding these precautions, noma appears, it is of 
the first consequence to maintain the strength by the use of 
concentrated liquid food, tonics, and stimulants. When per- 
foration of the cheek takes place, the act of swallowing is me- 
chanically interfered with. It is necessary then to resort to 
nutritious enemata, suppositories of quinine, and even the rectal 
administration of stimulants. 

The room in which the treatment is conducted must be large, 

* " Ziemssen's Cyclopaedia," vol. VI, p. 812. f " Diseases of Children," p. 218. 



AFFECTIONS OF THE MOUTH. 1 95 

airy, and so situated as to be exposed, for a part of the day at 
least, to the sun's rays. In summer the windows should be 
kept constantly open, and in winter they must be raised for 
at least fifteen minutes several times daily, the patient being 
warmly covered in the mean time. The air of the chamber 
must also be kept as pure as possible by the use of disinfec- 
tants. For this purpose cloths saturated with a solution of 
chlorinated soda or with Piatt's chlorides may be hung about 
the bed. 

Early, bold cauterization with the thermo-cautery of Paque- 
lin or the galvano-cautery is the most promising procedure ; 
strong sulphuric or muriatic acid, or the solid stick of nitrate 
of silver, are also recommended. All sloughs must be re- 
moved by scissors. The gangrenous spots should be fre- 
quently bathed with a strong solution of chlorate or perman- 
ganate of potassium, carbolic acid, or chlorinated lime. 
Pieces of lint soaked in one of these solutions may, with ad- 
vantage, be left in contact with the ulcer, if the child will tol- 
erate a fixed dressing. In cases of perforation, much of the 
wash will run into the mouth, and care must be taken to pre- 
vent its being swallowed. The mouth must be kept as clean 
as possible by repeated syringings with a solution of chlorate 
of potassium and carbolic acid, ten grains of the former and 
one grain of the latter to the fluidounce. 

When recovery occurs and is fully established, loss of tis- 
sue and the deformities resulting from cicatricial contraction 
may be, to some extent, remedied by plastic surgery. Early 
operations are not advisable, on account of their tendency to 
reestablish the disease. 



PARASITIC STOMATITIS— THRUSH. 

Thrush is characterized by the appearance of numerous, 
rapidly growing, white, curd-like flakes upon the oral mucous 



I90 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

membrane ; the latter being in a more or less catarrhal condi- 
tion, injected, swollen, hot and tender to the touch. The 
flakes are due to the development of a peculiar vegetable para- 
site, the saccharomyces albicans. Thrush occurs both as a 
primary and a secondary affection. 

Etiology. — The disease attacks sucklings, and is met with 
most frequently during the first three months of life. Children 
nursed at a healthy breast are never attacked, and rarely 
those belonging to the well-to-do classes, because of the 
attention given to cleanliness of the mouth and feeding appar- 
atus. 

Neglect of this fundamental principle, cleanliness, lies at the 
foundation of every case of primary thrush. Foulness of the 
mouth implies a condition in which the secretions and the 
food clinging to the mucous membrane are undergoing acid 
fermentation, a necessary precedent to the development of 
the fungus. Given this condition, thrush originates by con- 
tact with other cases, through the media of bottle-tips, spoons, 
tumblers, or cups used in common, or may arise without 
traceable contagion from carelessly kept and foul feeding 
utensils. 

The secondary form has the same direct causes, but arises 
during the course of gastro-intestinal disorders, especially 
those resulting from a too free dietary or the overuse of farin- 
aceous food. It may occur, also, as a complication of diseases 
that greatly impair the general nutrition, as the exanthemata, 
tuberculosis, spinal caries, etc. The disease is most prevalent 
during the summer months. 

The morbid appearances are the same in both forms. 
Prior to the appearance of the flakes, the oral mucous mem- 
brane is purplish-red and sticky, and its secretion, which is 
acid in reaction, shows, under the microscope, numerous 
spores, egg-shaped, sharply outlined, and hanging together in 
twos and threes. Soon, isolated white points, as large as a 





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ft 

q 

o 
u 

5 



o 
h 

o 

on 

o 



AFFECTIONS OF THE MOUTH. 1 97 

pin's head, appear on the inside of the cheeks. These rapidly 
increase in extent and number, involving other parts of the 
mucous membrane, and, often as early as the second or third 
day, large white flakes are formed. Later still, the whole 
cavity of the mouth, and in some cases even the pharynx and 
oesophagus, are covered. 

The patches, at first white, may become yellow, and some- 
times brown, if bleeding occur from rough handling of the 
mucous membrane. Their surface is somewhat velvet}-, and 
they are soft, breaking down like curd under the finger. 
During the first few days they adhere firmly to the mucous 
membrane ; afterward they become quite loose, and can be 
wiped off quite readily, leaving the epithelial surface intact. 

Microscopic examination of the fully formed patches reveals 
numerous irregularly developed fungoid filaments, with later- 
ally branching arms and buds, interspersed with round or oval 
sporules, and embedded in an amorphous, granular mass. A 
hardened section of a patch and the mucous membrane to 
which it adheres shows, in addition to these characters, a 
partial loss of epithelium, and a tendency on the part of the 
filaments to penetrate into the mucous glands and between 
the ceils of the deeper layers of the epithelium. 

The fungus seems to grow most freely upon squamous epi- 
thelium. It is never found in the nasal cavities, the larynx, or 
the trachea, and the presence of loose masses of it in the 
stomach may be regarded as accidental. On the other hand, 
it may be formed upon the lower segment of the rectum, the 
female genitals, and on abraded surfaces about the mouth, chin, 
and neck. 

Symptoms. — The primary form begins with heat, dryness, 
tenderness, slight swelling, and uniform redness of the mucous 
membrane of the mouth ; in other words, catarrhal stomatitis. 
The redness is combined with a purple tinge, which is most 
marked on the dorsum of the tongue. Here, too, prominence 



I90 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

of the fungiform papillae is noticeable. The child takes his 
food moderately well, but the meals are frequently interrupted 
on account of the pain caused by sucking. He is fretful and 
sleeps poorly. The bowels are moderately relaxed, the stools 
being liquid and yellow in color. In the course of twenty- 
four hours the thrush patches appear on the inside of the 
cheeks, and then extend to the lips, tongue, and palate. 
While extending they increase in size, though they usually 
remain isolated and rarely overstep the limit of the posterior 
border of the soft palate. With the appearance of the patches, 
there is increased fretfulness, more pain on sucking, occasional 
vomiting, and frequent evacuation of the bowels, the motions 
becoming green and acid. At some period, varying from six 
to twelve days from the beginning of the disease, the patches 
become loose and are removed by the act of sucking or in 
making applications to the mouth. The mucous membrane 
is left red but free from ulceration, and it soon returns to the 
normal condition . At the same time the general symptoms sub- 
side, and health is soon restored. Sometimes there are several 
crops of the fungus, but those coming last, being less firmly 
rooted than the first, are dislodged quickly and seldom pro- 
long the course of the disease beyond two or three days. 

In secondary thrush a history of previous gastro-intestinal 
or other disease will be obtained, together with an account of 
an immediately preceding diarrhoea and fever. Sometimes, 
however, the local symptoms are the first indications that the 
weak, badly nourished child is ill. The preliminary catarrh of 
the mouth is very marked, the mucous membrane being in- 
tensely red and shining. The patches are thick, are apt to 
change from a white to a yellow or brown color, soon cover 
the whole oral cavity, and frequently extend into the pharynx 
and down the oesophagus. They retain their attachment to 
the mucous membrane for a much longer period than in the 
idiopathic form. When they fall off they are quickly replaced 



AFFECTIONS OF THE MOUTH. 1 99 

by others, and a succession of crops is the rule up to the ter- 
mination of the case in death. The mouth is hot, dry and 
tender to the touch, and throughout presents an acid reaction 
to chemical tests. 

The appetite is gradually lost ; there is vomiting, either 
occasional or so constant that every morsel of food taken into 
the stomach is rejected at once, and obstinate diarrhoea, the 
stools being numerous, liquid, green in color, and acid. The 
abdomen is distended by flatus, and is tender to' pressure, par- 
ticularly in the epigastrium and right iliac region. Colic is a 
constant and annoying symptom. The pain is most severe 
just before or at the moment of an evacuation of the bowels. 

The skin is hot and dry and the frequency of the pulse 
increased, a rate of 120, 140, or 160 beats per minute being 
not unusual. 

The child sleeps badly, is restless and fretful, and when the 
pharynx is covered by the fungus, has a muffled, hoarse cry. 
The skin grows pale and inelastic, and the folds of the nates, 
the inner surface of the thighs, and the heels are reddened 
and eventually excoriated by the contact of the acid faeces. 
The strength and flesh are lost rapidly, the anterior fontanelle 
sinks, the eyeballs lie deep in their sockets, and the nose and 
chin are pointed. Toward the latter end of the attack, which 
is rarely protracted more than a few weeks, the patient assumes 
the facies of a little, wrinkled old man. His skin is cool, and 
he lies in an apathetic condition on the bed or nurse's lap, with 
scarcely enough strength to whine over his suffering until 
death, from exhaustion, ends the miserable life. 

Diagnosis. — Fragments of curdled milk adhering to the 
soft palate and cheeks resemble very closely the thrush patches 
in their earlier stage. The normal condition of the mucous 
membrane, and the readiness with which the curds can be 
wiped away, constitute the distinctive characteristics. 

Aphthous stomatitis bears a certain superficial likeness to 



200 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

thrush, but the differentiation is easily made by noting the 
fact that the yellowish-white spots of the former are depressed 
below the surface of the mucous membrane, being, in reality, 
the floors of ulcers, which in time are bounded by dark red 
borders. 

Microscopic examination is always the crucial test, and the 
presence or absence of thallus-fibrils and spores decides the 
question as to the nature of any deposit in the mouth. 

Prognosis. — The primary form is a very trifling affection 
and almost uniformly ends in recovery. In the secondary 
form the result is very often unfavorable. This is especially 
apt to be the case when the disease occurs in a child who has 
been much weakened by a continued course of improper food. 
Here, the hope of improvement depends upon the rapidity 
and completeness with which new material for nutrition can 
be introduced into the system. Anything, therefore, that tends 
to prevent this introduction deprives the child of his only 
chance of recovery, and the existence of thrush implies a con- 
dition of the digestive tract extremely unfavorable to the 
assimilation of food. Attendant diarrhoea aids, too, in pre- 
cipitating the fatal result. 

The mere presence, then, of the thrush patches is not to be 
regarded with as much anxiety as the conditions accompany- 
ing their formation. 

Treatment. — Much may be done to prevent the develop- 
ment of thrush by keeping the mouth clean and free from the 
abrasions caused by rough manipulation. A strict rule should 
be made to carefully wash out a child's mouth directly after 
each meal. This is best done with a large camel's-hair brush 
or a pledget of absorbent cotton moistened with warm water. 
The bottles and tips must also be kept immaculately clean. 
An equally important precaution is to select a proper diet. 
The question of diet is, of course, a very comprehensive one, 
and no further consideration can be given it in this place than 



AFFECTIONS OF THE MOUTH. 201 

to state the general law. Babies under six months old, who 
are unfortunate enough to be deprived of their mothers' milk, 
must be fed upon cows' milk so prepared that it may resemble 
as nearly as possible human milk. If farinaceous articles be 
used, they must be employed with the object of rendering the 
cows' milk more digestible by separating the curd, and not as 
the staple of the food. The regularity and the length of the 
intervals between meals, the selection of the proper quantity 
of food, and the preparation of each portion immediately 
before it is given, are matters worthy of the most careful atten- 
tion.* 

Such measures, together with attention to general hygiene, 
constitute an important part of the curative treatment after the 
appearance of the fungus. In idiopathic or in mild cases all 
that is required in the way of general treatment will be an 
alkali combined with a digestant, as in the formula already 
given for catarrhal and aphthous stomatitis ; f or, if the stools 
be numerous, green, and very acid : 

r£ . Magnesii carbonatis, ^j 

Syr. rhei aromatici, fgij 

Syrupi, f,! ss 

Aq. menthce piperita, q. s. adfjiij. M. 

SiG. — Teaspoonful every two or three hours, for a child three to six months 
old. 

The local treatment consists in keeping the mouth perfectly 
clean. It should be thoroughly washed, every hour at least, 
with absorbent cotton wrapped around the finger and wet with 
warm water. Immediately afterward, either one of the follow- 
ing lotions may be applied, upon a fresh piece of cotton : 

R . Sodii bicarbonatis, gr. x 

Aquae, f^j. M. 



* See Introduction. f See page 177. 

7 



202 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

R . Sodii hyposulphitis, gr. x 

Aquae rosse, . f ^j. M. 

& . Acid, carbolici, gr. ij 

Sodii salicylatis, 

Sodii boratis, aa gr. xxx 

Glycerini, fgij 

Aquse rosae, . . . . q. s. ad f^ j. M. 

It is essential immediately to destroy the cotton or other 
instrument used in cleansing the mouth or in carrying the 
lotion. 

The same principles are applicable to the treatment of 
secondary thrush. Every means must be employed to arrest 
the vomiting and diarrhoea, to improve the digestive powers 
and maintain the strength by proper food and stimulants. In 
some cases the abandonment of artificial feeding and the 
employment of a wet-nurse are essential to recovery. 



MEMBRANOUS STOMATITIS. 

A croupous membrane — that is, one in which the Klebs- 
Loeffler bacillus is absent — is sometimes encountered in the 
mouth, but this condition is extremely rare, the vast majority 
of cases of membranous stomatitis being diphtheritic. 

Diphtheria of the mouth may occur as a primary disease, 
though it is usually secondary, the membrane extending from 
the tonsils to the soft palate, tongue, gums, cheeks, and lips. 
When primary, the deposit appears first upon the lips, and 
thence may spread to any portion of the mucous membranes 
of the mouth ; it often runs a most insidious course. 

The symptoms are salivation, fetor of the breath, enlarge- 
ment and tenderness of the submaxillary lymphatic glands, 
the ordinary constitutional features of the infection, and the 
presence of the characteristic patches of false membrane 
upon the mucous surface. The membrane remains from three 



AFFECTIONS OF THE MOUTH. 203 

to six or more days, and then exfoliates or ulcerates away, 
leaving a denuded base. Hemorrhage takes place frequently; 
when due to mechanical irritation, it is of little moment, but 
occurring spontaneously is an evidence of grave cachexia 
even when trifling in amount, and when profuse may be the 
direct cause of a fatal termination. 

The diagnosis of the primary form can only be positively 
established by culture and the discovery of the Klebs-Loefner 
bacillus ; the secondary can readily be distinguished as an 
extension from tonsillar diphtheria. 

Treatment consists in removal of the false membrane, if 
this can be accomplished without traumatism ; the free and 
continuous employment of antiseptic washes, the early admin- 
istration of antitoxin and of the remedies of known efficacy 
in diphtheria, especially bichloride of mercury. Great care 
must be taken to maintain the patient's strength by strychnine, 
alcoholic stimulants, and nutritious, easily digested food. 



SYPHILITIC STOMATITIS. 

Syphilis may indirectly produce stomatitis ; first, by causing 
certain specific lesions, which give rise to disease of the mucous 
membrane generally, and secondly, by bringing about a greater 
susceptibility to the ordinary causes of oral disorders. 

The primary specific lesion is not often found in the mouth 
in infancy or childhood, but it may be produced by infection 
from a syphilitic nipple, and appears upon the tongue, lip, or 
tonsil ; the character of the sore does not differ from the 
initial lesion in the adult. 

The features of the inherited disease are much more fre- 
quently present, and appear as fissures, papules, mucous 
patches, and ulcers. 

Syphilitic fissures are the most common, and are found 
chiefly at the corners of the mouth, or upon one or other 



204 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

lip. They consist of tissue infiltrations which have been split 
in two by the movements of the lips, the fissures usually 
being in such a position as to form a continuation of the com- 
missure of the mouth and to leave one part of the infiltration 
nearer the lower, the other nearer the upper lip. They may 
be single or so numerous as to cause disfigurement and con- 
siderable pain on motion of the lips ; they run a very chronic 
course, healing with great difficulty and leaving permanent 
and distorting cicatrices. Papules arise at the angles of the 
mouth and upon the free margin of the lips. These elevations 
have moist surfaces, and show a tendency to break down in 
the centre or to split into fissures, and are painless when they 
do not involve the mucous membrane. Mucous patches may 
develop from fissures or papules, and are most frequently seen 
about the lips and upon the tongue. They are whitish in 
color, slightly raised above the surface of the mucous mem- 
brane, do not extend deeply into the tissues, have rounded 
borders, and vary in size from one-eighth to one-half of an 
inch in diameter. Syphilitic ulcers are found upon the tongue, 
their position depending upon some mechanical irritation, as 
from a sharp tooth. 

In hereditary syphilis the milk teeth are apt to be cut early 
and are prone to rapid decay, but show no other abnormality. 
The two upper, central incisors of the permanent set, how- 
ever, are quite characteristically affected in many cases. The 
alteration termed '/ Hutchinson's teeth " consists in dwarfing 
of the teeth in both length and width and notching of the 
centre of the free edge. The teeth, in addition to being 
smaller than normal, often taper regularly from the base to 
the edge, are rounded and peg-like in shape, incline either 
toward or away from each other, and do not meet the teeth 
on either side ; the notch is single, shallow, and crescentic in 
shape ; in its centre the enamel is deficient, and in this posi- 
tion there may be discoloration. 



AFFECTIONS OF THE MOUTH. 



205 



Syphilitic lesions of the mouth, being merely local mani- 
festations of a general condition, require the usual vigorous 
constitutional treatment. Locally, strict cleanliness must be 
enforced. Fissures and ulcers must be encouraged to heal by 
the application of nitrate of silver ; indurations and papules 
should be freely anointed with a mercurial ointment; and mu- 
cous patches should be dusted with a powder composed of 
equal parts of calomel and subnitrate of bismuth, or washed 
with a weak solution of bichloride of mercurv. 




Fig. 7. — Diagram Showing Eruption of Milk Teeth. 
[. Between the fourth and seventh months. Pause of three to nine weeks. 2, 2, 2, 2. 
Between the eighth and tenth months. Pause of six to twelve weeks. 3, 3, 3, 3, 3, 3. 
Between the twelfth and fifteenth months. Pause until the eighteenth month. 4,4, 
4, 4. Between the eighteenth and twenty-fourth months. Pause of two to three 
months. 5, 5, 5, 5. Between the twentieth and thirtieth months. 



DENTITION. 

ERUPTION OF THE TEMPORARY TEETH. 
Normally the twenty milk teeth are cut in groups, each 
effort being succeeded by a pause or period of rest. The 
accompanying diagram and table show the grouping, the date 
of eruption, and the duration of the pauses. The numbers, I 
to 5, indicate the groups to which the individual teeth belong 



206 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

and their order of appearance, and the letters, a and b } the 
precedence of eruption in the different groups. 

The dates given above show the time within which the dif- 
ferent teeth naturally may be expected. In regard to the 
period given for the eruption of the lower central incisors, I 
would state that the fourth month, although an early, is not 
a very rare time for their appearance. For example, in the 
past winter alone, I have seen five cases in which these teeth 
pierced the gum at this age. 

Often the teeth appear without the production of any symp- 
toms. Sometimes the edges of the gums lose their sharpness 
and become swollen, rounded, and reddened as the teeth ap- 
proach the surface. At the same time the saliva is increased in 
quantity, and the mouth is unnaturally warm and the seat of 
abnormal sensations, evidenced by the tendency to bite upon 
any object that comes to hand — in other words, there is a 
condition of mild catarrhal stomatitis. The consequent dis- 
comfort, though, is not sufficient to interfere with the child's 
appetite, good humor, or sleep, and when, after a few days, 
the margin of the tooth is free, all the local symptoms vanish. 

Abnormal dentition is manifested by departures from the 
laws of development already stated. The standard rules may 
be departed from in three ways : 

I. The appearance of the teeth may be premature. Chil- 
dren may be born with one or more of their teeth already cut. 
These are usually imperfect, and soon fall out, to be replaced 
at the proper age by well-formed milk teeth. Sometimes, 
however, they remain permanently, as in a few cases that 
have come under my own observation. Natal teeth are 
always incisors. Instances of the lower central incisors 
being: cut in the third month are not uncommon. Girls are 
more apt than boys to cut their teeth early, and, as an early 
dentition is likely to be an easy one, the occurrence is to be 
looked upon as fortunate. 



AFFECTIONS OF THE MOUTH. 20/ 

2. Dentition may be delayed. This deviation is more fre- 
quently seen and of more consequence than the first. Bottle- 
fed babies, as a class, are more tardy in cutting their teeth 
than those reared at the breast. With such, though healthy 
in every respect, a delay of one or two months is a common 
and not at all a serious event. On the contrary, whatever the 
method of feeding, if no teeth have appeared by the end of a 
year, it may be assumed that the child's general nutrition is 
faulty, or that rachitis is present. Delay does not necessarily 
imply difficulty in cutting the teeth, though the two conditions 
are often associated. 

3. The teeth may appear out of their regular order. Bottle- 
fed infants are most likely to show this irregularity, which is 
of some importance as an indication of general feebleness. In 
other instances, however, it is merely a family peculiarity, and, 
as such, bears no special significance. 

ERUPTION OF THE PERMANENT TEETH. 
The permanent teeth are cut in the following order : 

1. Four first molars, five to six years. 

2. Four central incisors, six to eight years. 

3. Four lateral incisors, seven to nine years. 

4. Four first bicuspids, nine to ten years. 

5. Four second bicuspids, ten to twelve years. 

6. Four canines, eleven to thirteen years. 

7. Four second molars, twelve to fourteen years. 

8. Four posterior molars, or " wisdom teeth," seventeen to 
twenty -one years. 

Of the twenty-eight teeth cut between the fifth and the fif- 
teenth years, the first and seventh sets are developed de novo. 
The other sets take the place of corresponding milk teeth, and 
appear in very much the same order, the lower central incisors 
appearing before the upper, the upper lateral incisors before 
the lower, the upper bicuspids before the lower, etc. 



2o8 



DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 



Figure 8 will aid in explaining the process. 

As these teeth approach the surface, absorption begins in 
the alveoli and at the roots of the deciduous teeth, and this 
continues until the latter are loosened and readily extracted, 
or if this be not done, until little is left but their crowns. 

When the first and second molars approach the surface, the 
gums, just as in primary dentition, may become red, swollen, 
rounded, and tender. The salivary secretion is increased, the 
mouth is hot, the patient complains of aching in the gum, and, 
on account of tenderness, refuses food requiring mastication. 



3 3 



4 r U^GQQfc , 




4 2 2^ 



Fig. 8.— Diagram showing Relation between the Permanent and Temporary 

Teeth. 
The figures i, 2, 3, etc., indicate the groups of teeth and the order of their appearance. 

With the other sets there is a gradual loosening of the super- 
imposed temporary teeth, pain on mastication, redness and 
tumefaction of the gum, and augmented flow of saliva. As 
there is no impairment of the general health, these trifling 
symptoms must be regarded merely as manifestations of the 
progress of a physiological process. 

Many diseases occurring in infancy were formerly attributed 
to dentition, but as pediatrics has been more carefully studied 
and better understood, one disorder after another has been 



AFFECTIONS OF THE MOUTH. 2C>9 

relegated to its proper etiological class, and teething is now 
regarded as a purely physiological process, unproductive of 
symptoms. All that can be said is that the interval between 
the fourth and thirtieth months of an infant's life — the period 
of primary dentition — is an era of great and widely extended 
physical progress. The teeth are advancing ; the follicular 
apparatus of the stomach and intestinal canal is undergoing 
development in preparation for the digestion and absorption 
of mixed food ; the cerebro-spinal system is rapidly growing 
and functionally very active, and the organs and tissues of the 



%/ 




Fig. 9.— Diagram of Lines of Incision in Lancing the Gums.* 

The above diagram plainly shows the lines of incision over the different teeth before 

eruption and after partial eruption. 

whole body are in a state of active change. This period of 
normal transition must also be one in which there is great sus- 
ceptibility to abnormal change, or disease, provided there be a 
causal influence at Avork. Such an influence usually originates 
outside of the body, as when there is exposure to cold or to 
contagion. 

With the recent and more correct understanding of the 
process of dentition, gum lancing has been less and less 
indiscriminately practised. The operation, however, must not 

* From "Diseases Incident to First Dentition." James W. White, M.D., 
D.D.S. 

18 



2IO DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

be absolutely condemned, for in certain well-selected cases, 
in which the gum over an advancing tooth is swollen and 
tense, and in which there is severe local pain, free incision 
gives prompt and lasting relief. Such incision, if carefully 
made with a clean blade, is free from direct danger ; in the 
formerly almost universal use of the lancet in every affection 
of teething infants, the risk lay in too great reliance upon the 
operation, to the neglect of proper dietetic and medicinal 
treatment. 

In lancing the gums the form of incision is important. As 
shown in figure 9, it must be linear in the case of the 
incisors and canines, and obliquely crucial in that of the 
molar teeth ; the tissues must be divided until the edge of 
the lancet distinctly touches the tooth. 



CHAPTER II. 
AFFECTIONS OF THE THROAT. 

SIMPLE PHARYNGITIS. 

Catarrh of the mucous membrane covering the soft palate, 
tonsils, and pharynx — simple or erythematous pharyngitis — 
is a common occurrence in children who have reached the 
third or fourth year, though it is rarely met with before that 
age. It may be either primary or secondary in origin. 

The anatomical lesion is hyperemia of the affected 
mucous membrane. This is red, swollen, softened, granular, 
and at times cedematous. 

Etiology. — The primary form is most prevalent during the 
winter and spring. Impaired health, from neglect, bad food, 
or insufficient clothing, predisposes to an attack ; while 
sudden changes in temperature and exposure to wet and cold 
are the chief excitants. One attack is often followed by 
others. The disease is not contagious, but many cases often 
occur simultaneously. Secondary pharyngitis, which will not 
be studied here, constantly accompanies scarlet fever and 
measles, and often complicates bronchitis and pneumonia. 

Symptoms. — An attack of simple pharyngitis of ordinary 
gravity begins with fretfulness and lassitude ; the child refuses 
food, and may vomit once or twice. Fever quickly follows, 
preceded by rigors, or, in children nearing the age of puberty, 
by a single distinct chill. This fever is quite out of propor- 
tion to the local symptoms. The temperature in the course 
of a few hours rises to 102 or 104 F., and often higher; 
the pulse runs up to 130 or 140 beats per minute; the 



212 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

respiration is correspondingly rapid, though easy ; the face is 
flushed and the skin dry. The voice becomes thick and 
husky, and there is a teasing unproductive, hoarse cough, 
which may assume a brazen character toward evening. Older 
patients may complain of dryness and fulness of the throat, 
of a sensation leading to frequent efforts at deglutition, or of 
difficulty and pain in swallowing food ; while infants manifest 
the latter conditions by refusing the breast or bottle. An 
entire absence of these subjective symptoms, however, is 
common. 

On inspection, the mucous surface of the soft palate, uvula, 
tonsils, and pharynx presents a reddened, tumefied, dry, 
granular appearance, and may be partially covered with flakes 
of whitish mucus or muco-pus. The tonsils are somewhat 
swollen, and at times the uvula is elongated and cedematous. 
The lymph glands about the angles of the jaw are slightly 
enlarged and tender to the touch. 

On the second day the fever abates, the temperature often 
falling to the normal line, but there is an elevation on each 
succeeding evening until the end of the fourth or fifth day, 
when the attack begins to subside. In the mean time the 
local symptoms increase. Throughout, the child is peevish 
and restless, sleep is disturbed, the tongue is heavily coated, 
and there is loss of appetite, increased thirst, and a tendency 
to constipation. 

In exceptional cases the disease is much more grave in 
type. These severe attacks begin with vomiting, excessive 
restlessness or drowsiness, occasionally convulsions, and 
always high fever, with a temperature reaching 106 or even 
more, and a rapid and bounding pulse. The affected mucous 
membrane becomes intensely red and covered with a muco- 
purulent secretion. All the ordinary symptoms are intensified, 
and, in addition, there may be mild delirium and a flushing of 
the entire cutaneous surface, suggesting the scarlatinal rash. 



AFFECTIONS OF THE THROAT. 213 

These attacks vary in duration from three to eight days, and, 
notwithstanding the alarming character of the symptoms, 
usually terminate in recovery. 

Diagnosis. — It is quite possible to overlook the presence 
of pharyngitis on account of the frequent absence of symptoms 
calling attention to the throat. Thus the sudden onset of high 
fever, with rapid pulse and respiration and dry cough, would, 
in the absence of difficult deglutition and pain in the throat, 
suggest an attack of croupous pneumonia. If, under the 
same conditions, the pharyngitis be ushered in by vomiting, 
the fever might readily be referred to a digestive disorder. 
Such errors are to be avoided only by making a rule to inspect 
carefully the throat in each doubtful case. A grave case, 
again, may in the beginning be taken for one of scarlet fever, 
the resemblance being increased by the uniform flushing of 
the surface. Distinction is to be found in the different course 
of the two diseases, and the non-appearance of certain charac- 
teristic symptoms of the exanthem. 

Care must be taken not to confound the white or yellowish- 
white patches of mucus or muco-pus adhering to the inflamed 
surface with diphtheritic membrane. The former can be wiped 
away easily, leaving the mucous membrane intact. 

Treatment. — If the case be seen on the first day, it is pos- 
sible greatly to reduce the severity of the attack by giving the 
child a hot mustard foot-bath,* putting him to bed in a prop- 
erly warmed room, and by cautiously administering aconite, 
with some saline laxative, as a small teaspoonful of magnesia 
in a wineglassful of strong lemonade. Under such circum- 
stances, tincture of aconite root may be given to a child of 
four years, in doses of a drop, every fifteen minutes until four 
drops have been taken, and subsequently the same dose every 

* The ordinary strength of such a bath for a child of three or four years is one 
tablespoonful of mustard-flour in two gallons of water. 



214 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

hour until an effect is produced on the pulse, or the heat and 
dryness of the skin are lessened. 

When the fever has been reduced in this way, or should the 
case not be seen until the second day, the following may be 
ordered : 

R . Potassii chloratis, gr. xxiv 

Syrupi, f^ss 

Aquse, q. s. adf^iij. M. 

SlG. — One teaspoonful every three hours in water, for a child of four years. 

If the fever returns as evening approaches, this mixture 
should be discontinued, and another foot-bath and a few doses 
of aconite given ; or some simple diaphoretic may prove suf- 
ficient, as one teaspoonful of liquor potassii citratis, at intervals 
of two hours during the night. 

Throughout the attack the diet should consist of milk and 
farinaceous articles prepared with milk, with a little meat broth 
as the fever subsides. A daily evacuation of the bowels must 
be secured, and the child must be kept in bed. 

Local treatment must not be neglected. If the child be 
able, he should gargle the throat every hour with a solution 
of chlorate of potassium, ten grains to the fluidounce. If too 
young to do this, the same solution should be applied to the 
throat at short intervals with a mop of absorbent cotton. 
Painting the throat daily with a solution of nitrate of silver 
(gr. v to f Sj) hastens the cure. At the same time, it is well 
to redden the skin of the neck with some such liniment as : 

R. 01. terebinthinse, f.^j 

01. olivse, f|iij. M. 

SlG. — Apply twice daily. 

Grave cases require no alteration of this plan. It is well, if 
there be great restlessness, to repeat the foot-bath, or even to 
give several full warm baths of ten minutes' duration. If there 
be intense inflammation of the pharynx, the neck should be 



AFFECTIONS OF THE THROAT. 2 I 5 

enveloped in a poultice. Clogging of the throat by tenacious 
mucus may demand an emetic. 

When convalescence begins, the diet must be more liberal, 
and restoration to perfect health is hastened by administering 
a bitter tonic, as tincture of nux vomica, or compound tincture 
of gentian, in appropriate doses, three times daily. 



SUPERFICIAL CATARRH OF THE TONSILS. 

In this affection there is a simple hyperemia of the mucous 
membrane covering the tonsils, accompanied by moderate 
swelling of the glands. It is produced by the same causes, 
and usually occurs as an element, merely, of general pharyn- 
gitis. In the exceptional cases in which it exists in an iso- 
lated form, the tonsils will be found reddened and moderately 
swollen, and several yellowish-white points, due to retained 
follicular secretion, will be seen on their surfaces. The local 
subjective and the general symptoms are the same as those of 
pharyngitis, and they yield to the same measures of treatment. 



ACUTE FOLLICULAR TONSILLITIS. 

This condition, in the great majority of instances, is due to 
an infection ; but there are other cases in which it is purely 
catarrhal or produced by auto-intoxication in certain types of 
disordered digestion ; it must, therefore, be studied under 
two heads : viz., (a) Infectious Follicular Tonsillitis, and (b) 
Simple Follicular Tonsillitis. 

(a) INFECTIOUS FOLLICULAR TONSILLITIS. 
This form is also called " croupous tonsillitis," " pseudo- 
diphtheria," and most frequently " diphtheritic sore throat." 
The latter is both incorrect and misleading, as this affection 
has no connection with true diphtheria, the Klebs-Loeffler 



2l6 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

bacillus being uniformly absent from the culture of the ton- 
sillar exudate. 

Etiology. — The disease may occur at any period of child- 
hood, but is very rare during the first, and uncommon until 
after the second year of life. Isolated cases of this disease 
may be encountered at any season of the year, but more or less 
extended epidemics arise during the late autumn, winter, and 
early spring months. Children who are physically depressed 
by improper feeding and unsanitary surroundings, and those 
who are acutely debilitated by exposure to cold and wet in 
winter or to excessive heat in summer, or who are over- 
fatigued, are more prone to attack. The direct cause, how- 
ever, is local infection by one or other species of streptococci 
or staphylococci. 

Symptoms. — The affection is characterized by moderate 
enlargement with marked congestion of the tonsils and by an 
exudate which appears upon the reddened mucous membrane 
in the form of patches or puncta. They are from one to 
two lines in diameter, and are situated around the openings of 
the follicles, which they appear to extend into and line. The 
false membrane is closely attached to the underlying mem- 
brane, extends but little above its surface, and is white, thin, 
and translucent. Several puncta may run together, forming 
large patches, but the composite nature of these can be 
readily discovered by wiping away the loose muco-purulent 
matter which accumulates over and about them. Together 
with the tonsils, the chain of muco-lymphoid glands behind 
the posterior pillars of the fauces, and the glands of the 
pharynx generally, may be the seat of pseudo-membranous 
deposits, but the mucous membrane generally remains free. 

The typical alterations in the condition of the throat are 
preceded by several days of depression, loss of appetite, and 
general malaise. The actual attack is ushered in by rigors, 
followed by a rapid rise of temperature to 102° or even 105 



AFFECTIONS OF THE THROAT. 2\J 

F., and by considerable increase in the frequency of the pulse. 
There is headache, pain in the back and limbs, anorexia, in- 
creased thirst, a furred tongue, and sluggish bowels. The 
throat is painful, especially in swallowing, and there is 
moderate enlargement and tenderness of the submaxillary 
lymphatic glands. Transient albuminuria is sometimes noted. 
After a period varying from two to four days, the fever abates, 
the pulse becomes more normal, the pain in the back and 
legs disappears, that in the throat subsides, and the exudate 
clears away from the tonsils leaving the mucous membrane 
intact but reddened. The attack is followed by considerable 
depression and general feebleness ; the swelling and tender- 
ness of the cervical lymph glands may remain for a fortnight 
or more, and at times suppuration takes place, though this is 
fortunately an unusual sequel. 

Diagnosis. — Infectious tonsillitis is most apt to be con- 
founded with true diphtheria ; in fact, it is often classed with 
this disease by a group of practitioners outside the circle of 
the regular profession, who are fond of impressing their 
patients, and, by magnifying trifles, apparently work rapid 
and marvelous cures of dangerous diseases. It is true that 
in certain instances the resemblance between the two condi- 
tions is very close, and that a diagnosis can only be absolutely 
established by a culture of the membrane and the discovery, 
by microscopic examination, of the presence or absence of the 
Klebs-Loeffler bacillus. In the majority of cases, however, 
a reasonably certain opinion can be based upon the gross 
appearances of the exudate in the throat and the general 
symptoms. 

The diphtheritic false membrane may appear first at the ori- 
fices of the follicles of the tonsils, but so far from remaining 
limited to these positions and to the submucous glands of the 
throat, it rapidly extends — within twenty-four hours — to the 
pillars of the fauces, the velum, or the walls of the pharynx. 



2l8 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Again, the diphtheritic membrane is deposited in large plaques, 
which are thick, considerably elevated above the surface of the 
mucous membrane, gray or dirty yellow in color, and evi- 
dently necrotic. The exudate of tonsillitis, on the other 
hand, appears in puncta, is thin, translucent, white, looks 
clean, and shows no indication of undergoing a necrotic 
change. In the latter disease, too, the general symptoms de- 
velop more rapidly and are more sthenic ; the pain in the throat 
is greater and the course is much more quickly run, the symp- 
toms often abating markedly at the end of twenty -four hours, 
and disappearing entirely in from two to four days. 

The prognosis is almost uniformly favorable, the worst 
sequel being suppuration of one or more of the cervical 
lymphatic glands, which may require surgical interference 
and may prove dangerous. 

Treatment. — The child must be confined to bed and placed 
upon a diet of milk and broths, given in small quantities — four 
to six ounces — at intervals of two hours during the day, and 
once or twice at night if there be much weakness. 

The medicinal treatment should be inaugurated with a 
course of calomel, gr. -^ with g r - j of bicarbonate of sodium 
every two hours for six doses, for a child of four years. Two 
hours after this course is finished, chlorate of potassium and 
tincture of the chloride of iron should be administered, as in 
the following prescription : 

R . Potass, chloratis, gr. xxiv 

Tr. ferri chloridi, rr^ xxxvj 

Syr. zingiberis, f % ss 

Aquse, q. s. adf^iij. M. 

SiG. — One teaspoonful every two hours. 

If there be decided depression, 3 drops of tincture of nux 
vomica or gr. ss-j of sulphate of quinine may be ordered every 
fourth hour, and moderate alcoholic stimulation is sometimes 
required. 



AFFECTIONS OF THE THROAT. 2IQ. 

High fever is best treated by hot mustard foot baths and 
small repeated doses of tincture of aconite. 

Locally, the throat should be thoroughly sprayed twice 
daily with peroxide of hydrogen, pure, unless too great pain 
is produced, when it may be diluted one-third or one-half. 
In addition, a gargle or spray of chlorate of potassium — 
gr. x to f§j — should be used every two hours. The surface 
of the neck over the swollen cervical glands must be well 
rubbed with warm camphorated oil at intervals of four or six 
hours. 

When the throat becomes clean and convalescence is estab- 
lished, the diet should be slowly increased up to the standard 
for the age of the patient, the local treatment discontinued, 
and the potash and iron mixture replaced by a tonic, as : 

R . Tr. nucis vomicae, TT\, xxx 

Acid, nitro-muriat. dil., TT^ xxxvj 

Elix. cinchonas calisayae, q. s. ad f ^ iij. M. 

Sig. — One teaspoonful three times daily after food. 

As marked general debility often follows an attack of infec- 
tious tonsillitis, the patient must not be allowed to leave his 
bed and be up and about too early, and exposure as well as 
overfatigue must be carefully guarded against. 

(5) SIMPLE FOLLICULAR TONSILLITIS. 
In this disease there is, in addition to superficial hyperemia, 
a catarrh of the lacunae or follicles of the tonsils. According 
to the extent of the disease, several or all of the follicles 
become filled with a yellowish-white, curd-like material, con- 
sisting of epithelium and pus. When thin, this flows away ; 
but, when thick, it is removed with difficulty, collects and 
distends the lacunae, and may undergo desiccation, or even 
become calcified. The parenchyma of the tonsils becomes 
hyperaemic, and there is an infiltration of serum and a prolif- 
eration of the gland cells. 



220 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Etiology. — The affection is a common one after the fifth 
year. It is most apt to be met with in the winter and spring, 
but it may occur at any season. Exposure to wet and cold 
is usually considered to be the exciting cause, but an attack 
may quite as frequently be traced to overeating, associated 
with excitement and fatigue. One attack predisposes to 
others, and I have seen many patients who are invariably 
affected after gorging themselves with rich food, pastry, or 
candy. A combination of all of these causes — so well afforded 
by that w^orst of institutions, a child's party — invariably pro- 
duces a crop of cases. 

Symptoms. — When due to overeating, the attack usually 
sets in on the day succeeding the indulgence. It begins with 
headache and lassitude ; the tongue becomes frosted ; there is 
thirst, anorexia, and nausea, often followed by vomiting. 
Toward the evening of the first day the face becomes flushed, 
the skin hot and dry, and the pulse rapid. The bowels are 
sluggish, and the urine is scanty, high-colored, and lateritious. 
On the morning of the second day the fever disappears, but it 
may return in the afternoon, and this course is sometimes 
maintained for three or four days, when convalescence is estab- 
lished. In the mean time the anorexia and constipation con- 
tinue, the patient sleeps badly, but the strength is quickly 
recovered after the attack terminates. 

When the affection is due to exposure alone, there is less 
headache, and no nausea or vomiting. 

Whatever the cause, the local symptoms are the same. 
They consist of a sensation of dryness and heat in the throat, 
repeated efforts to clear the throat, difficult and painful deglu- 
tition, increased salivation, a nasal intonation of the voice, and 
a heavy, offensive breath. On inspection, a catarrhal condi- 
tion of the palatine arches and pharynx is observed. The 
tonsils are enlarged, sometimes sufficiently so as almost to 
meet one another ; their enveloping mucous membrane is red- 



AFFECTIONS OF THE THROAT. 221 

dened and swollen, and their surface is dotted with yellowish- 
white points, corresponding in number, shape, and size with the 
follicles involved. On pressing the tonsils, ill-smelling masses 
of varying size and consistency may be pressed out. These are 
also expelled by hawking, or are forced out in deglutition and 
swallowed with the food. In whichever way removed, they 
leave the orifices of the follicles more widely open and gaping 
than in health. There is some tenderness on pressure beneath 
and behind the angles of the jaw. 

The diagnosis is easily made from the appearance of the 
tonsils, and from the fact that gentle pressure with the finger 
will force out one or more masses of retained secretion — a 
pathognomonic sign. There is no doubt that these cases are 
by some classed as diphtheritic, though none but the most 
inexperienced could confound with diphtheritic membrane the 
numerous yellowish-white points, of irregular shape and size, 
depressed below or projecting beyond the well-defined lips 
of the follicles, and which, as already stated, often can be 
expelled by pressure on the tonsils. Again, the difference 
between this affection and the punctated exudate of infectious 
follicular tonsillitis must strike any careful observer. 

The prognosis is always favorable, except that one attack 
predisposes to others, which may lead to chronic hypertrophy 
of the tonsils. 

Treatment. — If the attack be traced to overeating, the 
administration of an emetic would naturally suggest itself as a 
preliminary. This, however, is rarely necessary, as the initial 
vomiting empties the stomach sufficiently. Usually, the first 
steps are to place the child's feet in a hot mustard bath, then 
put him to bed, and give, according to the age, one or two 
grains of calomel at once, or in broken doses if there be much 
nausea. If, on the first night, the fever be high, tincture of 
aconite should be resorted to ; if more moderate, an effer- 
vescing draught, like the following, will suffice : 



2 22 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

.&. Acidi citrici, % iss 

Aquae, f^iij- M. 

Sig. — Solution No. I. 

B: • Potassii bicarbonatis, ^j 

Aquae, f^iij- M. 

Sig. — Solution No. 2. 
A teaspoonful of each solution is to be poured into a tablespoon or glass and 
taken while effervescing. 

This draught has the advantage of checking nausea at the 
same time that it reduces fever. 

The food must be restricted to small quantities of milk and 
lime water (3 to 1), or weak broths in case milk disagrees. 
On the second day it is only necessary to look carefully after 
the diet, to allow nothing but milk and broths, keep the patient 
in bed, and give during the day the following : 

J£ . Pepsini (Fairchild's), 

Sodii bicarbonatis, aa 3J. 

M. et ft. chart. No. xij. 
Sig. — One powder every three hours for a child of six years. 

The effervescing mixture may still be used in the early night 
if the fever be high enough to require it. 

Such measures should be continued until convalescence is 
established, care being taken to keep the bowels regular with 
calomel in broken doses. Then the diet may be gradually 
increased and a bitter tonic given. 

If the cause be exposure to wet and cold, the general treat- 
ment must be the same as for pharyngitis. 

Rheumatic and lithsemic children are very prone to this 
form of tonsillitis. Under these circumstances salol or salo- 
phen, in appropriate doses, should be added to the treatment. 

The local treatment embraces counter-irritation of the skin 
of the neck ; touching the tonsils once daily with a solution of 
nitrate of silver, gr. v to f§j ; and frequent gargling with : 



AFFECTIONS OF THE THROAT. 22 3 

& . Potassii chloratis, gr. lxxx 

Acid, carbolici, gr. ij 

Glycerini, f^j 

Aquae, q. s. ad f:§viij. M. 

SiG. — Use as a gargle every hour. 



PERITONSILLAR ABSCESS OR SUPPURATIVE 
TONSILLITIS. 

Quinsy is a comparatively rare disease in childhood and is 
scarcely ever met with before the twelfth year. When it does 
occur, some family predisposition can generally be traced, the 
most common predisposing element being the rheumatic dia- 
thesis. Fatigue and exposure are the exciting causes. The 
direct cause of the suppuration is, as in all instances, infection by 
specific pathogenic micro-organisms, entering from some source 
either external or internal. It is most frequent during spring 
and autumn. One attack predisposes to others. It may arise 
as a primary affection or as a complication of scarlatinous, 
variolous, or pseudo-membranous anginas. One or both tonsils 
may be affected. 

Morbid Anatomy. — At first there is intense hyperemia 
with serous infiltration of the cellular tissue, and the tonsils 
sometimes become swollen to more than double their size. 
The inflammation may now undergo resolution. Otherwise an 
infiltration of small cells takes place, into and between the fol- 
licles, into the inter-lacunar connective tissue, and in the cap- 
sule. Retrogression is still possible, or, failing this, a new 
formation of reticulated substance takes place, resulting in per- 
manent hypertrophy — a frequent termination of repeated at- 
tacks in children. If the inflammation be very intense, an 
abscess forms, but suppuration is not the usual result of 
tonsillitis occurring before puberty. With these conditions 
there is always associated general pharyngitis and often simple 
follicular tonsillitis. 



224 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Symptoms. — The disease begins with rigors or a distinct 
chill, followed by sneezing, epistaxis, headache, pain along the 
Eustachian tube, loss of appetite, and fever, with languor and 
muscular prostration during the day, and mild delirium at 
night. Soon the patient complains of dryness and burning in 
the throat, difficulty and pain in deglutition, and the voice 
becomes nasal. If the throat be inspected, the mucous mem- 
brane of the soft palate and pharynx is seen to be red and 
swollen, and one or both tonsils are reddened and enlarged, 
often presenting several whitish-yellow points of retained fol- 
licular secretion. If one tonsil only be affected, the ©edema- 
tous uvula will be pushed to the opposite side — an important 
sign. 

The symptoms gradually increase in severity. The tempera- 
ture ranges from 99 or ioo° F.,in the morning, to 102 or 104 
in the evening, and the pulse from 1 10 to 120 ; but the respi- 
ration, though snoring, is little increased in frequency. Pain 
grows worse and deglutition becomes more difficult ; the voice 
assumes a peculiar, thick, nasal tone ; the breath has a heavy 
odor ; the salivary secretion is increased and dribbles from the 
mouth ; the tongue is heavily furred, and the bowels are 
sluggish. The child's face wears an apathetic expression, is 
red or dusky in hue, and there is dulness of hearing. Talk- 
ing is painful, and so also is any movement of the jaw. On 
this account it is difficult to obtain a view of the throat ; but if 
such be had, the tonsils, when both are affected, are seen to be 
intensely congested, and so much swollen that they meet ; 
or, when only one gland is involved, it often extends beyond 
the median line. The day is divided between the listless in- 
action of prostration and the uneasy tossing of discomfort ; 
and the night, between the restlessness of fever and the 
wandering of delirium. What little sleep is obtained is inter- 
rupted by snoring. 

The crisis usually occurs on the fifth day, although it may 



AFFECTIONS OF THE THROAT. 22 5 

be postponed until the eighth. If the tonsillitis ends in reso- 
lution, the fever rapidly subsides, disappearing entirely in 
twelve hours ; the local symptoms simultaneously abate and 
convalescence is rapid. When the inflammation ends in the 
formation of new tissue and hypertrophy of the glands, the 
acute manifestations givQ place to a train of symptoms to be 
described in the following section. Finally, if suppuration take 
place, there is a chill, followed by high fever. The abscess 
soon points toward the mucous surface of the gland, and, un- 
less opened by lancing, is broken by an effort at deglutition or 
in an examination of the throat. The quantity of pus dis- 
charged is ordinarily small, and is swallowed, as a rule. After 
the opening of the abscess, the child passes at once from a 
condition of great distress to one of comparative comfort, and 
strength and health are soon regained. 

The diagnosis of quinsy is unattended with difficulty, and 
the prognosis, so far as life is concerned, is always good, though 
the danger of chronic hypertrophy must not be forgotten. 

Treatment. — If the patient can be seen when the peculiar 
tone of the voice, the pain in the line of the Eustachian tubes, 
and the deflection of the uvula indicate the beginning of ton- 
sillitis, it is possible to abort, or, at least, greatly reduce the 
intensity of the inflammation. For this purpose he must be 
put to bed, and properly proportioned doses of tincture of 
aconite must be administered every half hour until an effect 
is produced on the temperature and pulse, while small bits of 
ice must be swallowed at intervals of ten minutes. If there 
be a rheumatic tendency, salicylate of sodium, salol, or sa- 
lophen should be administered in full doses for the age, in 
place of, or in conjunction with, the aconite. At the same 
time it is well to apply a sinapism to the side of the neck cor- 
responding to the affected gland. Since the introduction of 
cocaine I have often succeeded in aborting tonsillitis by thor- 
oughly mopping the affected parts three times daily with a 
19 



226 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

four per cent, solution of this drug. Even in cases where 
this favorable result was not obtained, the cocaine so far 
allayed pain as to permit liquid food to be swallowed with 
ease. This is an invaluable aid in the treatment of severe 
quinsy occurring in feeble children. 

When the case is not seen till later, the indications are to 
encourage resolution or hasten suppuration, and to maintain 
the strength. To fulfil the first, the neck should be enveloped 
in a poultice, the throat should be repeatedly gargled with 
warm water, and steam from an atomizer should be constantly 
inhaled. The strength is to be kept up by administering all 
the concentrated liquid food that it is possible for the patient 
to swallow, and by using suppositories of quinine. The latter 
may be ordered in this way : 

$ . Quininse bisulphatis, gr. xviij 

01. theobromae, ^iij. 

M. et ft. supposit. No. xij. 
Sig. — Use every four hours for a child six years of age. 

On account of the difficulty in swallowing, it is well to 
avoid ordering any medicine by the mouth except a diaphor- 
etic, such as the solution of the citrate of potassium, and an 
occasional dose of some saline laxative. When there is much 
restlessness or delirium at night, it is well to give bromide of 
potassium, in ten-grain doses, by the mouth or rectum. 

If an abscess forms, a somewhat rough pressure of the 
finger against the involved tonsil will hasten its rupture, but 
incision is a better method of treatment and often lessens the 
duration of suffering by twenty-four hours or more. 

After the crisis is past, the diet must be increased and a 
tonic ordered, as : 

& . Tr. ferri chloridi, f ^j 

Quininse sulphatis, gr. xij 

Syrupi zingiberis, f Jj 

Aquae, q. s. ad f^iij. . M. 

SiG. — One teaspoonful, in water, three times daily for a child six years old. 



AFFECTIONS OF THE THROAT. 22J 

The subsidence of the tonsils to their normal size is hastened 
by painting them twice daily with : 

R. Acidi tannici, 5jj. 

Glycerini, f^j. M. 

For prevention, gargles of cold water and astringents, appli- 
cations of the glycerole of tannin, and measures to maintain a 
high standard of health, and especially to counteract any 
rheumatic tendency, should be employed. 



HYPERTROPHY OF THE TONSILS. 

Chronic enlargement of the tonsils is slow in its develop- 
ment, and must be considerable in degree before giving rise 
to definite symptoms. Consequently, the disease is rarely 
recognized before the third or fourth year of life, although its 
commencement in early infancy is quite possible. It is com- 
mon between the seventh and twelfth years. 

Etiology. — The predisposing cause of tonsillar hypertrophy 
is a peculiar constitutional tendency recently termed " lym- 
phatism." This condition has for its local manifestations 
enlargement of the faucial tonsils, of the naso-pharyngeal tonsil, 
or " adenoids," and of the muco-lymphoid glands of the 
pharynx and of the base of the tongue. This diathesis is not 
identical with scrofula, though it seems to be allied to, and is 
often associated with, it. Exposure to cold and dampness 
and repeated tonsillar inflammation are the ordinary exciting 
causes. As the symptoms are aggravated by any passing 
angina, more cases demand treatment during the winter and 
spring than at other seasons. 

Symptoms. — The first to attract attention is loud snoring 
during sleep, due to pressure upon the velum, and obstruction 
to the passage of air through the posterior nares. At the 
same time there is a decided nasal twang to the voice. Ex- 



228 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

amination shows marked projection of both tonsils, or, more 
rarely, of one only ; the follicular orifices are widely open and 
very distinct, and several of them may present the yellowish- 
white points of retained secretion. The investing mucous 
membrane is pale, as a rule, but it may be traversed by arbo- 
rescent blood-vessels. Such a degree of hypertrophy and the 
accompanying symptoms sometimes disappear spontaneously 
with the development of the mouth and vocal organs attendant 
upon puberty. 

When the glands are so much enlarged that they touch in 
the mid-line of the throat, there are added to the other symp- 
toms mouth-breathing, a constant hacking cough with labored 
respiration, and difficulty of hearing, due partially to pressure 
upon the orifices of the Eustachian tubes, and partly to a state 
of habitual congestion kept up in the surrounding parts. The 
dyspnoea is much worse at night, and the little patient often 
starts from sleep in a state of terror. It may be so grave as 
to threaten life and necessitate tracheotomy. 

When enlargement- — so great as to decidedly obstruct the 
passage of air through the nose and give rise to constant 
mouth-breathing — has existed from an early age, noticeable 
anatomical changes take place. The nostrils become ex- 
tremely small and compressed, while the superior dental arch 
retains the narrowness of infancy, not allowing room for the 
teeth, which, in consequence, overlap one another. The palate, 
also, becomes unusually high and arched. The face is dull, 
almost idiotic in expression. Furthermore, the obstacle to 
the free entrance of air prevents the lungs being readily filled 
in inspiration, so that a partial vacuum is formed between them 
and the chest-wall, to fill which the external air-pressure forces 
in the yielding parietes. The effect of external pressure is 
most marked where the resistance is least, namely, at the base 
of the thorax, and a constant and long-continued repetition 
of this leads to the production of a gutter of variable depth 



AFFECTIONS OF THE THROAT. 229 

and three or four inches in width, extending laterally from the 
lower part of the sternum, and to a projection forward of this 
bone. Any tendency to pulmonary phthisis is increased by 
this deformity, and if tuberculous disease be present, the im- 
pediment to the entrance of air and the constant irritation of 
the air passages maintain a condition most unfavorable to its 
arrest. Mastication and deglutition are impeded in proportion 
to the extent of hypertrophy, and with the disturbed sleep and 
especially the imperfect oxygenation of the blood resulting 
from the mouth-breathing, lead to great impairment of nutrition 
and general development. 

Treatment. — Moderate enlargement of the tonsils in a 
weakly child will sometimes disappear when puberty is passed, 
or as health is regained under a course of tonics. The best 
tonic is syrup of the iodide of iron, in doses often drops three 
times daily for a child of eight years of age. It is well to 
paint the tonsils once every day with one of the following 
astringents : 

R. Tr. ferri chloridi, , f^j 

Glycerini, q. s. adf^j. M. 

R. Liq. iodi comp., fo*J 

Glycerini, q. s. ad f^j. M. 

When there is marked hypertrophy, good results are ob- 
tained in suitable cases by the careful use of the electro-cau- 
tery. Children of six or eight years readily submit to this 
treatment provided thorough cocaine anaesthesia be produced 
before each application of the heated wire. A gargle contain- 
ing tannic acid must also be used four times daily, as : 

& . Acidi tannici, 3 ss 

Glycerini, fo ss 

Aquae, q. s. ad f 3 viij. M. 

Syrup of the iodide of iron should be given three times 



23O DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

daily, care being taken not to administer it at the time that the 
gargle is used. Cod-liver oil is also serviceable. 

Together with this treatment enough nutritious food must 
be given to keep up the strength. This can be done with 
readiness, since, in spite of the size of the tonsils, there is usu- 
ally no pain, and little difficulty in swallowing. 

Excision, however, is the best and most rapidly successful 
procedure when there is excessive enlargement, and is a neces- 
sity if, at any time, there is dangerous interference with res- 
piration. Constant or frequent cough, or the presence of any 
other symptom suggestive of phthisis, also demands an imme- 
diate operation. Tonsillotomy is free from danger ; in fact, it 
may be classed as one of the safest even of minor operations. 

If, after removal of a portion of the tonsils or their reduc- 
tion by treatment, the chest is slow to regain its natural form, 
the use of light dumb-bells and carefully regulated gymnastics 
are of much service. Dupuytren's method of reducing the 
sternal prominence by placing the child's back against a wall, 
and pressing it firmly backward with the palm of the hand 
during each act of expiration, is efficient, notwithstanding its 
apparent roughness. 



NASO-PHARYNGEAL ADENOID HYPER- 
TROPHY. 

At the vault of the pharynx there is situated a composite 
gland closely resembling in structure the faucial tonsils and 
called the " third" or "pharyngeal tonsil." This, in health, 
is of small size, but it readily undergoes hypertrophy, and 
then interferes markedly with the general health and develop- 
ment of the child. 

Etiology. — The condition of constitution already described 
as " lymphatism " predisposes to hypertrophy of this as well 
as other muco-lymphoid glands, so also does inherited syph- 



AFFECTIONS OF THE THROAT. 23 1 

ilis and tuberculosis ; but enlargement of the third tonsil 
frequently occurs in children who are otherwise strong and 
healthy. The exciting causes are those of ordinary catarrh : 
exposure to cold and dampness and to rapid and extreme 
atmospheric changes. 

Symptoms. — Adenoid growths present two classes of 
symptoms, one due to an associated naso-pharyngeal catarrh, 
the other to mechanical obstruction. 

Catarrhal symptoms are most prominent in infancy, pro- 
ducing a persistent mucous or muco-purulent and sometimes 
bloody discharge from the nose. This discharge is rarely 
present during the warm, dry months of summer, but in win- 
ter is continuous, or is produced or aggravated by exposure 
to cold or dampness. Frequent attacks of otitis also occur, 
and the voice is apt to be thick and hoarse. With the catarrh 
the infant shows evidences of obstruction of the naso-pharynx 
by difficulty in blowing the nose, a nasal voice, and mouth- 
breathing. The latter feature may be constant, but is usually 
noticed only during sleep, when the inspiration becomes 
labored and is noisy or even stertorous. The difficulty in 
breathing is most marked when the patient lies upon the back 
or approximates this posture, so there is much turning about 
in bed and restless, uneasy sleep, in the unconscious endeavor 
to find some position in which breathing can be carried on 
with ease. 

In older children nasal catarrh may be present or is readily 
produced by exposure, but the obstructive features are always 
more accentuated. The plugging of the posterior nares leads 
to constant oral breathing, and the habitually open mouth, by 
altering the normal adaptation of certain of the muscles of the 
face, causes changes in the shape of the soft and developing 
facial bones, and gives rise to a characteristic physiognomy. 
The lower jaw hangs down and lengthens the face, the nose 
is pinched or the nostrils distended, the corners of the mouth 



232 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

and eyes have a drawn appearance, and the general expression 
is vacant and stupid or almost idiotic. From alteration in air 
pressure the hard palate becomes pointed or " high-arched "; 
the upper jaw, in turn, is diminished in transverse diameter 
and pointed in front, and the teeth, especially the incisors, 
are crowded into irregular groups or rotated on their axes. 
The forcing upward of the palatine arch produces deflection 
of the septum of the nose, which aids the original growth in 
obstructing nasal respiration and encourages the development 
of hypertrophic rhinitis. 

When the adenoid hypertrophy begins early in life, and 
especially in rachitic cases, the mouth-breathing changes the 
shape of the chest walls, producing pigeon-breast with 
prominence of the sternum and deep lateral gutters, or de- 
cided depression of the lower third of the sternum. 

Impairment of hearing due to obstruction of the orifices of 
the Eustachian tubes is another common result of pressure. 

These symptoms are associated with general languor, rest- 
less sleep, a thick, hoarse voice, headache, mental depression 
or sluggishness, inability to fix the attention or to learn, and, 
when the disease is of long standing, with anaemia and the 
indications of malnutrition. Finally, the hypertrophy may be 
the reflex cause of various neuroses, as chorea, incontinence 
of urine, asthma, spasm of the glottis, and even epileptiform 
convulsions. 

Diagnosis. — An absolutely certain opinion can only be 
based upon a digital exploration and the discovery of a soft, 
velvety, irregular mass in the vault of the pharynx. Without 
this, however, it is usually possible to make a diagnosis from 
the expression of the face, the mental sluggishness, impaired 
hearing, thick voice, the mouth-breathing, disturbed sleep, 
the anaemia and depraved nutrition, and the history of a 
chronic nasal catarrh which is little affected by treatment. 

Deafness and hoarseness must not direct attention from the 



AFFECTIONS OF THE THROAT. 233 

nasopharynx to the ears or larynx as the seat of disease ; and 
it is well to remember that the manifestations of obstructive 
pressure do not depend solely upon the extent of hyper- 
trophy, since a small growth in a narrow pharynx is competent 
to cause marked symptoms. 

Prognosis. — Adenoid growths always improve and give 
rise to less decided symptoms in the warm, dry atmosphere 
of the summer months, though they have no tendency to 
spontaneous recovery. Their normal course is to increase in 
size up to a certain point, and then remain stationary until 
puberty, when they atrophy partially, or, in the case of the 
smaller growths, completely ; but they leave their imprint in 
the deformed face and chest and in the sluggish intellect. 
In addition, the arrest of development resulting from long- 
continued anaemia and poor nutrition is a handicap during 
the remainder of the patient's life. 

Adenoid subjects readily contract diphtheria when exposed, 
and in them any intercurrent disease — as diphtheria, scarlet 
fever, measles, or whooping-cough — is more prone to result 
seriously on account of the enfeebled general health. 

Treatment. — The medical man can do little in these cases 
beyond maintaining the patient's strength by tonics and well- 
selected, nutritious foods. His office, after making the 
diagnosis, is to insist upon removal of the growth and to place 
the case in competent surgical hands. 



RETROPHARYNGEAL ABSCESS. 

This form of abscess is not limited to any period of child- 
hood, but is of infrequent occurrence. It maybe due to trau- 
matism, or to caries of the cervical vertebrae, though, as a 
rule, it depends upon suppurative inflammation of the lymph- 
atic glands embedded in the posterior wall of the pharynx ; 
the direct cause of the inflammation being infection by the 



234 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

pus-producing micro-organisms. This infection is usually 
secondary to an inflammatory process in the superficial and 
associated muco-lymphoid glands of the fauces and naso- 
pharynx. Thus the abscess may follow follicular tonsillitis, 
peritonsillar abscess, or the various types of tonsillitis and 
pharyngitis that attend the exanthemata ; occasionally the 
source of infection may be rhinitis, or, yet more infrequently, 
a suppurative otitis. In its initial stage the disease is a lymph- 
adenitis, and the inflammation may either terminate in resolu- 
tion or proceed to completion in the formation of an abscess. 

The symptoms are deep-seated pain, difficulty in swallow- 
ing and after a time in breathing. On lying down the respira- 
tory embarrassment is increased, sometimes to such an extent 
as to threaten suffocation. There is, also, great stiffness of 
the neck, retraction and immobility of the head, and a diffuse 
swelling of the lateral cervical surfaces, often greater on one 
side than the other. If now the finger be carried over the 
root of the tongue, and down toward the pharynx, a firm or 
fluctuating swelling will be felt, more or less filling the pharyn- 
geal canal, and projecting over the opening of the glottis. On 
inspecting the throat, the swelling can usually be seen, occu- 
pying one or other side or the middle of the pharynx, and 
pressing forward the uvula and soft palate. The investing 
mucous membrane may be normal or congested. Sometimes 
the mouth cannot be sufficiently opened to permit of inspec- 
tion, and at others the abscess is seated so low in the pharynx 
that no tumor can be seen ; when so seated, a comparatively 
small abscess may threaten suffocation. 

Duparcque enumerates three symptoms indicating the for- 
mation of an abscess behind the cesophagus : viz., severe pain, 
produced even by moderate pressure on the larynx and upper 
part of the trachea ; the entire suspension of respiration by 
such pressure ; and displacement of the larynx forward and 
to the right. 



AFFECTIONS OF THE THROAT. 235 

Fever and cerebral manifestations may or may not be 
present, and initial symptoms are far from being uniform, so 
that, unless an examination of the throat be made, the disease 
may be overlooked in its early stages. Ordinarily, however, 
the diagnosis can be made without difficulty. 

Diagnosis. — Without care, the disease may be confounded 
with oedema of the glottis, and with true or false croup. In 
the first affection, inspection of the throat shows that the swell- 
ing is seated in the larynx and not in the pharynx. In diph- 
theritic laryngitis some false membrane can usually be dis- 
covered on the tonsils or half arches ; in spasmodic laryngitis 
the appearances of simple pharyngitis alone are present if 
the throat shares at all in the catarrh, and in both forms of 
croup the voice is altered, being extinct or hoarse, a symptom 
entirely absent in retropharyngeal abscess. 

Prognosis. — Recovery is the usual outcome of the disease, 
the abscess discharging spontaneously ; under these circum- 
stances the course is run in from five to fifteen days. In some 
cases, however, a prompt diagnosis and the evacuation of the 
abscess by puncture are required to avert death by suffoca- 
tion, or to prevent burrowing of the pus into the oesophagus, 
larynx, mediastinum, or the pleural cavity. 

The prognosis is very grave when the disease accompanies 
cervical caries. Suffocation from the sudden, spontaneous 
discharge of pus is an exceptional event. 

The treatment is simple. As soon as the abscess has 
formed, it must, when within easy reach, be punctured, as near 
the median line of the pharynx as possible, the blade of the 
bistoury having been carefully wrapped with adhesive plaster 
to within a fourth of an inch of its point. If the abscess 
be situated low down, a trocar and cannula is the safer instru- 
ment to employ. 

Intubation should be performed when the puncture is un- 
productive and not followed by relief of the dyspnoea ; but if 



236 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

this operation be mechanically impossible or prove ineffectual, 
tracheotomy will be required. 

For several days after the incision, occasional pressure 
must be made by the finger on the tumor, to insure thorough 
evacuation of the pus. At the same time a general tonic and 
supporting treatment is necessary. 



CHAPTER III. 
AFFECTIONS OF THE STOMACH AND INTESTINES. 

ACUTE GASTRIC CATARRH. 

This is one of the most common ills of childhood, since, in 
addition to arising idiopathically, it attends every disease 
in which there is pyrexia, as well as many of those that are 
apyretic. 

The idiopathic form may occur at any age, but is infre- 
quent in breast-fed infants. Its origin under such circumstances 
is always traceable to some abnormal condition of the mother's 
milk. The ordinary predisposing causes are general feeble- 
ness of constitution, exposure, and imperfect hygiene. Expo- 
sure is also an excitant, but the chief of this class of causes 
is the administration of food that is either bad in quality or 
excessive in quantity. 

The anatomical lesion is hyperemia of the mucous mem- 
brane of the stomach, producing an increased secretion ol 
mucus, and a diminished flow of gastric juice. 

Symptoms. — An attack of what the nurse calls " indiges- 
tion " comes on in infants after a bottle of changed milk or a 
"taste" of some unusual food has been given ; in older chil- 
dren after a mixed and indigestible meal, particularly when this 
has been attended by exposure and excitement. The child, after 
a few hours, becomes listless, has a hot, dry skin, loses appetite, 
is thirsty, sleeps restlessly, and, if old enough, complains of 
headache, abdominal discomfort, and nausea. Then there is 
vomiting of sour-smelling, curdled milk, or of whatever food 
is in the stomach in a more or less imperfectly digested state. 



238 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

The first act of eme^is is easy, but if repeated, as is often the 
case, there is painful retching, and nothing is expelled save a 
little bile-stained mucus. Soon the tongue becomes covered, 
except at the very tip and edges, which are red, with a thick 
white or yellowish-white fur, through which the fungiform 
papillae protrude as bright scarlet points. The breath has a 
heavy or sour odor. There is some fever, the temperature 
ranging from one to three degrees above normal, and the 
pulse counting 110 or 120 per minute. There is moderate 
tenderness on pressure in the epigastric region. The bowels 
are confined, and the urine is lessened in quantity and later- 
itious. These symptoms continue from twenty-four to forty- 
eight hours. 

The attack sometimes terminates suddenly, with several 
loose faecal evacuations. In other cases the fever gradually 
subsides, the nausea and thirst diminish, the tongue cleans, 
and the appetite slowly returns, convalescence extending over 
a period of two or three days. 

The diagnosis is readily established by the history of the 
causation, the character of the vomit, the state of the tongue, 
the moderate fever, the epigastric tenderness, and the course 
of the attack. 

The prognosis is always favorable so far as recovery is con- 
cerned, but it must be remembered that one attack always in- 
creases the susceptibility to another. 

Treatment. — Complete rest, on the nurse's lap for infants, 
and in bed for older children, is essential. During the first 
twelve or twenty-four hours there is no inclination for food, 
and if any be forced, it is quickly rejected. Consequently it 
is better to avoid any attempt at ordinary feeding until the 
stomach becomes settled. Thirst is to be relieved by cool 
water, or carbonic-acid or Vichy water, and the only nourish- 
ment to be allowed is albumin water or weak barley water 
given in doses of two to four fluidounces every two hours. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 239 

Such measures are also useful to allay nausea and vomiting ; 
but if these symptoms are at all obstinate, a mustard sinapism, 
just strong enough to redden the skin, should be applied to 
the epigastrium, and the following prescription ordered : 

R . Liquor, calcis. 

Aquae cinnamomi, aa fr-ij. M. 

SiG. — One to two teaspoonfuls, according to the age, at intervals of fifteen 
to thirty minutes, as necessary. 

Or, if the tongue be heavily coated and the breath foul, 
gr. T V or i of calomel with gr. j of bicarbonate of sodium 
every hour for six doses. Frequently repeated small doses 
of the effervescing citrate of potassium, or of the effervescing 
draught already mentioned (page 222), are efficient. A good 
plan, too, is to divide the contents of each package of a 
Seidlitz powder into a number of equal parts, about twelve 
for a child of three years ; dissolve a portion from each in a 
small tablespoonful of water, pour them together, and admin- 
ister in a state of effervescence. This may be repeated, at 
first, every half-hour, later at longer intervals ; rarely more 
than six or eight doses are required to check the vomiting. 
This and the calomel course have the additional advantage of 
acting gently on the bowels. 

In those exceptional cases in which, after an unsuitable 
meal, there is headache, fever, epigastric discomfort, and 
nausea without vomiting, it is necessary, as a preliminary 
measure, to induce emesis by draughts of warm water or a 
sufficient dose of syrup or wine of ipecacuanha. 

When vomiting has ceased and nausea disappeared, the 
patient must begin to take food. At first one ounce of sound 
milk diluted with half an ounce, or even an ounce, of lime 
water or barley water may be given every two hours ; and the 
quantity increased and the dilution lessened as the stomach 
regains its functional powers. Weak mutton, veal, or chicken 
broth, free from grease, and diluted with one-half or an equal 



24O DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

quantity of barley water, sometimes suits when milk cannot 
be retained. 

While attention is paid to the diet, care must be taken to 
secure a free evacuation of the bowels by a mercurial followed 
by a saline laxative. Beyond this, all that is required is to 
administer properly proportioned doses of bicarbonate of 
sodium and pepsin before each meal, for three or four days, 
and to gradually increase the diet to its normal standard as 
healthy digestion is restored. 



CHRONIC GASTRIC CATARRH. 

This affection presents so many points of dissimilarity, 
according to the age of the patient, that it is desirable to study 
it under two heads, namely, chronic gastric catarrh in infants, 
and chronic gastric catarrh in children who have passed the 
period of first dentition. Further, since chronic catarrh of 
the stomach is always attended by imperfect gastric digestion, 
and since food imperfectly digested in the stomach is unfitted 
for intestinal digestion, and must act as an irritant and lead to 
intestinal catarrh, it is impossible to absolutely isolate the two 
conditions in a clinical description. This is so markedly the 
case in older children that it seems best to defer the study of 
the second division of the subject to a later section, headed 
"chronic gastro-intestinal catarrh," and at present to consider 
only — 

CHRONIC GASTRIC CATARRH IN INFANTS. 

This dangerous affection, sometimes termed "chronic vom- 
iting," is of common occurrence. 

Morbid Anatomy. — In the earlier stages there is a simple 
hyperemia of the gastric mucosa, but a long continuance of 
this condition thickens and loosens the membrane, changes 
its color to ashen-grey, and leads to an excessive formation 
of tenacious mucus, while greatly lessening the secretion of 



AFFECTIONS OF THE STOMACH AND INTESTINES. 24 1 

efficient gastric juice. Coincident enlargement of the gastric 
glands also gives an appearance of roughness to the surface 
of the mucous membrane. 

Etiology. — The period of life between the third and sev- 
enth months furnishes by far the greatest number of cases. 
Sex and season are not influential. Infants fed entirely at 
the healthy breast are very rarely affected. 

The predisposing causes belong to the class of influences 
that lower the readily depressed vitality of early infancy ; for 
instance, overcrowding, filth, want of sunlight and fresh air in 
dwelling-rooms, insufficient clothing, and too early weaning. 

The one great exciting cause is the administration of un- 
suitable food. Sometimes the breast milk departs so much 
from its normal quality that it acts as an irritant upon the 
delicate mucous membrane and produces catarrh ; or it may 
flow so freely that the child swallows more than he can digest, 
and the surplus, having undergone chemical change in the 
stomach, produces a like result. But the harm commonly 
arises from the use, in artificial feeding, of food that is either, 
by its nature, unsuited to the feeble digestive ability of in- 
fancy, or which, though good in itself, is rendered hurtful by 
being kept in unclean vessels, and given from foul or badly 
constructed bottles. 

Of the first, or essentially bad articles of diet, the farinaceous 
foods are the most harmful, because, for the digestion of 
starch, both saliva and pancreatic juice are required, and these 
secretions are absent until the fourth month, and not fully 
established for some time later. Further, when subjected to 
the action of a ferment in the presence of heat and moisture — 
conditions existing in the stomach — these substances readily 
undergo fermentation resulting in the formation of acid which 
acts as an irritant to the susceptible mucous membrane. Con- 
sequently, such a diet used, as it too often is, to the exclusion 
of milk, must be a very active cause of gastric catarrh. The 



242 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

habit of allowing or encouraging infants to bolt bits of table- 
food and drink tea is quite as injurious ; perhaps, though, this 
indiscretion is more apt to produce chronic diarrhoea than 
chronic vomiting. 

Perfectly pure milk will be quickly changed and rendered 
irritating and unfit for use by being poured, when delivered 
by the milk-man, into pitchers or cans not properly cleansed 
from the remains of the supply of the day before. The 
smallest quantity of sour, bacteria-laden milk is sufficient to 
rapidly produce a like change in several pints of the fresh 
fluid when mixed with it. The same is true of unclean bottles 
and tips to which the dregs of former meals adhere in the 
form of small white curds. In these the change begins as 
soon as the fresh milk is added, and advances far before the 
child finishes the meal. 

A knowledge of the etiological factors explains why by far 
the greatest sufferers are foundlings, foster-children, children 
born to poverty, and those belonging to women who engage 
themselves as wet-nurses, or are obliged to earn their living 
by working away from home. 

Symptoms. — The first symptom is vomiting, occurring at 
irregular intervals, and resulting in the expulsion of curdled, 
sour-smelling milk, or whatever food is in the stomach, stained 
yellow or green by bile. The characters of the vomit, how- 
ever, soon change, the bile disappearing and only a clear, 
watery fluid, containing fragments of food, being ejected. In 
addition, there are eructations of sour or even fetid gas. The 
surface of the body is normal in temperature or cool, the skin 
is harsh and sallow, and an eruption of strophulus may cover 
the trunk and arms. The lips are red and dry, the tongue is 
coated with a thick, dry, yellow fur, with dull red fungiform 
papillae protruding at intervals ; the mouth is parched, thirst 
is increased, and milk or water is taken greedily, only to be 
quickly vomited again. The bowels are constipated, and 



AFFECTIONS OF THE STOMACH AND INTESTINES. 243 

when an evacuation does occur, it is attended by great strain- 
ing, and the feces appear in small, round, hard, light-colored 
lumps, often enveloped in mucus ; sometimes moderate 
diarrhoea alternates. The abdomen is distended and tympan- 
itic, and there is great tenderness over the epigastrium. 
Flesh is rapidly lost, the anterior fontanelle becomes sunken, 
the child is very fretful, has an aged and anxious expression 
of face, and a deep furrow may be noticed passing downward 
from the alae of the nose to encircle the mouth, giving to the 
lips the appearance of projecting. 

This condition continues, with occasional brief periods of 
improvement, for several months. Then the vomiting be- 
comes more constant, occurring both after food and in the in- 
tervals of feeding. It is excited by any disturbance ; such a 
trifling act as wiping the mouth, for example, being sufficient 
to bring on an attack. The stomach seems now to have lost 
its power to even begin the digestion of the blandest food, for 
if milk be given, it is vomited uncurdled and in the same state 
as when swallowed. Emaciation progresses very rapidly. 
The skin, dry and inelastic, hangs in loose folds from the 
limbs, and is apparently too large for the wasted body. It 
has a muddy color, and exhales an offensive, sour odor. The 
face is pinched, the eyes are sunken, though bright, with 
pearly sclerotics ; the nose is sharp and the cheeks are hol- 
low. The infant lies with the knees drawn up against the 
abdomen, and to this position they are at once returned when 
straightened out ; often the legs are moved about uneasily, in- 
dicating abdominal pain. There is little sleep either by day 
or night. Fretfulness is constant, with an occasional breaking 
out into loud, painful cries, or, as weakness increases, into low 
wailings. The tongue is dry and heavily coated, the bowels 
continue constipated, and, toward the end, the abdomen be- 
comes retracted. The pulse grows weak and frequent in pro- 
portion to the failure in general strength, and the temperature 



244 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

falls below normal ; the thermometer, placed in the rectum, 
often registering but 97 ° F. The breath is sour, and the 
scantily secreted saliva, perspiration, and urine are all very 
acid. As death draws nearer, the surface is perceptibly cool 
to the touch, the hands and feet become blue, patches of thrush 
appear upon the inside of the lips and cheeks, the little patient 
lies utterly exhausted, dozing or half unconscious, and for 
several days before the fatal termination the only evidences of 
life are the gentle rise and fall of the chest in breathing and 
the occasional expression of pain that flits across the face. 

Sometimes, in the last few weeks of the attack, certain of 
the symptoms become exaggerated, and may suggest cerebral 
involvement. In this condition there is deep depression of 
the fontanelle, dilated pupils, transient flushing of the face, 
great languor, heaviness of the head, drowsiness, semi-stupor, 
and even coma with stertorous breathing. Indications of pain 
and fever are, however, absent. The sunken fontanelle shows 
a deficiency in the amount of blood in the brain, but, as sug- 
gested by Parrot, there may be, in addition to this source of 
the symptoms, some toxic element analogous to that of urae- 
mia. Thrombosis of the cerebral sinuses and intracranial 
hemorrhages are also occasionally found after death, but their 
connection with the ante-mortem phenomena is by no means 
uniform. 

When the disease terminates favorably, the vomiting be- 
comes less in amount, some little of the food being retained ; 
it also begins to occur at longer and longer intervals, and fin- 
ally stops entirely, though there is great liability to a return 
on the slightest indiscretion. Afterward all the other symp- 
toms disappear except the constipation, which is apt to be 
obstinate. 

Diagnosis. — The protracted course, the frequent and ob- 
stinate vomiting of sour liquid, and the excessive emaciation, 
mark the disease with sufficient distinctness. The association 



AFFECTIONS OF THE STOMACH AND INTESTINES. 245 

of vomiting and constipation, and the development of the cere- 
bral features, are suggestive of tuberculous meningitis. This 
disease is to be excluded by the depressed condition of the 
fontanelle, the regularity of the pulse, the tympanitic abdo- 
men, and the apyrexia. 

Prognosis. — Chronic vomiting is a dangerous affection ; 
still, with careful feeding and judicious management many pa- 
tients recover, and become stout and robust. The course, in 
unfavorable cases, is prolonged, extending from two to four 
or even six months. 

Treatment. — The first and most essential step in the suc- 
cessful management is a careful regulation of the diet. There 
are two ends to be attained : first, to give the stomach as much 
rest as possible ; and second, if a sour odor of the breath and 
body indicates that fermentation is going on in the viscus, to 
stop this process by withholding fermentable materials. 

In cases of moderate severity, where the vomiting has fol- 
lowed premature weaning, with a substitution of farinaceous 
food for the natural, a return to the breast is indicated. Or, 
if this be impracticable, the food must consist exclusively of 
sterile milk guarded with lime water or diluted with barley 
water. For a child of three months a good proportion is one 
part cream, two parts milk, and three parts lime water or 
barley water, with sugar of milk and a little salt. Of either 
of these mixtures two fluidounces may be given every two 
hours, though the only guide to the proper quantity is the 
power of retention ; and if one measure be rejected, less must 
be given at the next feeding, until the proper amount is ascer- 
tained. Subsequently, it may be increased as the stomach 
becomes retentive. 

In more severe and long-standing cases, attended by symp- 
toms of acid fermentation, it is still advisable, with young 
infants, to try a return to the breast. In doing this, the fact 
that the mere act of sucking is sometimes sufficient to excite 



246 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

vomiting must be remembered. So, before discarding the 
mother's milk as a food, an effort should be made to administer 
it with a spoon, after pumping it from the breast. It may 
then be retained and digested. However, the majority of 
patients in this stage of the disease can digest neither breast 
milk nor any of the ordinary preparations of cows' milk, and 
time and even life may be saved by adopting at once an unfer- 
mentable diet, as a mixture of — 

Fresh cream, f ,! ss 

Whey, fgj 

Barley water, f Jj ; 

Or— 

Weak veal broth (half a pound to the pint). 
Thin barley water ; in equal quantities. 

Either food is best given cold and in small quantities at 
short intervals. One teaspoonful at a time is enough in bad 
cases ; but when the amount is so small, the dose must be 
repeated every ten or fifteen minutes. As improvement occurs, 
the amount of food and the length of the intervals should both 
be increased. It is important always to forbid the use of a 
bottle and to feed with a spoon. A careful observance ot 
these details is frequently rewarded by a rapid cessation of the 
vomiting. After the stomach has been retentive for forty- 
eight hours an effort may be made to return to a milk diet and 
the bottle. The change may be begun with a very dilute milk 
mixture, and even this should be partially predigested at first. 

For a patient three months old make each bottle of food as 
follows : 

Cream, I tablespoonful (f ^ss) 

Milk, 3 tablespoonfuls (f 3 iss) 

Water, 5 tablespoonfuls (f^iissj 

Peptogenic milk-powder, I level teaspoonful. 

After mixing, heat cautiously over a flame for six minutes, stirring constantly 
with a spoon, and tasting often, so that it shall not become too hot to be 
sipped — 1 1 5 F. Cool to 98 F. before administering. 
Feed every two to two and a half hours from 5 A. M. to 10 P. M. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 247 

In case each bottle cannot be prepared separately — by far 
the better way — the whole quantity for each day may be pre- 
pared in the morning, as follows : 

Cream, . 8 tablespoonfuls (f^iv) 

Milk, 24 tablespoonfuls (f 3j xij) 

Water, 40 tablespoonfuls (f 3 xx). 

Peptogenic milk-powder, 8 level teaspoonfuls. 

Heat slowly, so as to bring to a full boil at the end of ten minutes ; fill eight 
graduated nursing bottles to the five-ounce mark, cork with cotton, and 
place in nursery refrigerator; beat to 98 F. at time of administration. 

This food is to be given at first in portions of two fluid- 
ounces, and this quantity gradually increased until double the 
quantity at a feeding is borne with ease. Then, to return- to 
an unpeptonized diet, gradually reduce the time of heating ; 
finally replace the milk-powder by sugar of milk and salt, and 
carefully increase the proportion of milk until a food properly 
modified for the age is attained. For example : 

Milk, fjij 

Cream, f^ ss 

Milk sugar, ^j 

Salt, a pinch 

Water, f 3 iss ; 

given from a perfectly clean bottle, every two and a half hours. 
The substitution of lime water or barley water for water is 
advisable in case of slow digestion with colic. 

The importance of preparing each meal separately, and im- 
mediately before it is served, must not be overlooked. 

The second necessary step is to attend to the clothing and 
hygiene. A light, long-sleeved, woolen shirt, drawers of the 
same material, and thick worsted stockings, must be worn ; the 
latter especially should be insisted on, as it is essential to keep 
the feet warm. In addition it is well to envelop the abdomen 
with a flannel binder. The clothing must be changed at 
reasonable intervals. Should it become soiled by vomit, it 
must be taken off at once and carried out of the room. The 



248 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

frequency of such accidents can be much lessened by placing 
a towel under the child's chin and over his chest, to receive 
the vomited matter. This, too, when soiled, is to be removed 
immediately and replaced by another, perfectly dry and fresh. 
The sick-room must be light and well ventilated, and no articles 
of body or bed clothing moistened with vomited matter should 
be allowed to remain in it a moment ; the proper temperature 
is 6S° F. 

If the feet remain cold in spite of stockings, they should be 
rubbed from time to time with the dry hand, or with some stimu- 
lating liniment — oil of turpentine, f.jij, and olive oil, f§ij ; if 
this does not warm them, the legs, as far as the knees, may be 
put in a hot mustard foot-bath for five minutes. Hot flaxseed 
poultices made light and dashed with mustard, will, when worn 
over the belly, relieve pain and fretfulness ; the same result 
follows repeated applications of the stimulating liniment. To 
promote free action of the skin, the whole body should be 
sponged with warm water twice a day, and afterward anointed 
with warm olive oil, which must be gently rubbed into the 
surface with the pulps of the fingers. If there be great pros- 
tration, a full bath of ioo° F., with or without mustard, may 
be resorted to, the body being immersed from one to three 
minutes. Under such circumstances, it may also be necessary 
to envelop the legs in cloths wrung out of hot mustard water, 
and to keep bottles or rubber bags filled with hot water in close 
contact with the body in order to encourage reaction and main- 
tain a normal temperature. 

The ordinary medicines for relieving gastric irritability are 
of little avail in checking the vomiting in chronic catarrh of 
the stomach. The remedy that seems to possess most power 
to accomplish this is liquor potassii arsenitis. The proper 
dose for a child of three months is half a drop, three times 
daily, administered simply in a teaspoonful of water or com- 
bined with an alkali and aromatic, as : 



AFFECTIONS OF THE STOMACH AND INTESTINES. 249 

r£ . Liquor potassii arsenitis, fflx'j 

Sodii bicarbonatis, gr. xxiv 

Aquae rnenthae pip., q. s. ad f^iij. M. 

SiG. — One teaspoonful in a little water, three times daily. 

Tincture of mix vomica is also very useful ; it may be ad- 
ministered in half-drop doses three times daily, combined with 
bicarbonate of sodium and an aromatic, as in the prescription 
just given. 

When Fowler's solution and nux vomica fail, there are 
several other drugs that may be tried. These are wine of 
ipecacuanha in drop doses even* three hours, calomel one- 
twelfth of a grain every four hours, and salicylate of sodium 
half a grain every two hours. 

While these medicines are being administered, the bowels 
should, in case of constipation, be regularly evacuated by 
laxative enemata. 

Prostration demands stimulants. The best is old whiskey, 
which may be given in ten-drop doses every two hours ; but 
the guide for the dose, as well as for the proper time to com- 
mence administration, is the condition of the fontanelle. 

When convalescence begins half a drop of tincture of nux 
vomica, or fifteen drops of the ferrated elixir of cinchona, may 
be prescribed, and the tonic effects of fresh air and sunlight 
must be utilized by taking the child out of doors when the 
weather permits. 



ULCER OF THE STOMACH AND H^MAT- 
EMESIS. 

This disease is not very uncommon in new-born infants, but 
is decidedly rare afterward. It may occur as a single, minute, 
round ulcer, with a perforating tendency, as in adults, or as 
numerous small scattered erosions which stud the surface of 
the mucous membrane and assume the appearance of ulcerated 



2 50 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

follicles. The perforating ulcer has been ascribed to all the 
various causes which are held to be potent in producing the 
gastric ulcer of adult life, and it is probable that for children 
after they are weaned the pathology of the two may be the 
same ; but, for newborn infants, circulatory disturbances which 
ensue somewhat suddenly at birth, the sudden arrest of the 
placental stream, the gradual development of the pulmonary 
circulation, associated as it often is with partial atelectasis, so 
potently predispose to venous stagnation in the abdominal 
viscera as to give much ground for the belief that congestion, 
and even ecchymosis, are at the root of the ulceration. 

The scattered ulceration has been found under such varied 
clinical conditions that it is impossible to attach any definite 
meaning to it, although one may suppose with reason that it 
is the result of some chronic catarrh. 

Vomiting of blood and melaena are the only indications 
which point to the existence of an ulcer of the stomach in the 
infant. A healthy child who within a few hours of its birth 
begins to vomit blood and to pass pitchy matter per anum, 
may have a gastric ulcer. More than this we cannot say, for 
the same symptoms may certainly be present without any 
ulcer. In the few cases in w T hich a gastric ulcer is present in 
older children, the symptoms, if definite, should be as in 
adults — epigastric pain and vomiting. The follicular ulcer 
cannot be diagnosed, and has always been found accidentally 
upon the post-mortem table. 

Tuberculous ulceration of the stomach is occasionally met 
with, but it has no symptoms apart from those of tabes 
mesenterica. Hemorrhage from the stomach, without ulcera- 
tion, may take place during the first few days of life and is one 
of the most frequent forms of " hemorrhagic disease" in 
the newborn. In older children bleeding sometimes occurs 
without fixed gastric lesion, and may be a symptom of several 
constitutional diseases : namely, purpura, scurvy, haemophilia, 



AFFECTION'S OF THE STOMACH AND INTESTINES. 25 I 

and at times malaria. If blood leaking from the infant's nose 
or pharynx be swallowed, it is usually vomited ; so also if 
sucked from a fissured or ulcerated nipple during the act of 
nursing : this spurious haematemesis must not be confounded 
with the true form. 

In some cases of gastric hemorrhage there is no haemat- 
emesis, and the diagnosis must be established by the general 
symptoms, which are those well known to attend internal 
hemorrhage ; usually, however, there is both vomiting of 
blood and its expulsion with the stools. Vomited blood is 
bright red in color if expelled soon after the bleeding, has 
occurred, dark brown and resembling coffee grounds if it has 
remained long in the viscus. Blood that has passed from the 
stomach into the intestines is voided with the faeces as a black, 
tarry material. 

Spurious hemorrhage can be distinguished by the absence 
of alteration in the child's general health and by a careful 
examination of the patient's nose and pharynx and the nurse's 
nipple. 

Haemoptysis has its own characteristic features readily 
establishing its presence or absence. 

The bleeding in many cases of gastric ulcer is so quickly 
fatal that no treatment is available. In less rapid cases, and 
in haematemesis, favorable results are sometimes secured by 
keeping the stomach at rest, nothing being allowed by the 
mouth but small bits of ice and sips of water. Nourishment 
must be given by enema, and the rectum also utilized for 
medicinal treatment, which consists in the administration ol 
opium in small but sufficient doses to maintain quiet. Stimu- 
lants may also be given by this channel, or whiskey and 
strychnia may be introduced hypodermatically if necessary. 
When the bleeding is checked, gastric feeding may be 
cautiously begun, and bismuth subcarbonate or silver nitrate 
may be administered in appropriate doses. 



2 52 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

SOFTENING OF THE STOMACH (GASTRO- 
MALACIA). 

This condition has received a great deal of attention, and 
some of the most distinguished writers upon the diseases of 
children have credited it with being a distinct disease, but, to 
my mind, with insufficient reason. Of symptoms it has none 
which is in any way characteristic, and the appearances 
found after death are identical with those of post-mortem 
solution. Whether this, as well as other changes which are 
cadaveric in their nature, may not at times commence during 
the last hours of life may perhaps be an open question, but 
that the change is, in all cases, essentially what has been 
described as post-mortem solution there is no doubt. 

Goodhart has twice found evidence of a gastric solution ol 
the lung, which had gone on during the life of the patient. 
Into the appearances of the parts it is needless to enter 
further than to say that they showed a distinctly peculiar 
broncho-pneumonia, and that in each case there had been a 
moribund condition associated with vomiting for some days 
before death. Now, it is obvious that such a condition has 
no right to the position of a disease ; it would never have 
occurred had the circulation of the patient been at its proper 
tension. It was the result of an ebbing life, not a disease, 
which caused death. So it is with the gastro-malacia ol 
children. It is the result of exhausting disease of any kind, 
and is virtually, if not literally, a post-mortem change. 



CHRONIC GASTRO-INTESTINAL CATARRH. 

This disease is common in children who have passed the 
first dentition, and bears to them somewhat the same relation 
that chronic vomiting does to infants. Among the latter it is 
very uncommon, perhaps because the anatomical position and 



AFFECTIONS OF THE STOMACH AND INTESTINES. 253 

greater irritability of the stomach in the early months of life 
favor the rapid expulsion of improper or partially digested 
food, and the irritating products of gastric fermentation, which 
would otherwise, as in older children, pass through the pylorus 
and induce catarrh of the intestinal mucous membrane. The 
disease is met with in two forms, differing merely in the degree 
of catarrh. For convenience, the}' ma}' be considered sepa- 
rately ; as, habitual indigestion, in which the catarrh is moder- 
ate in degree ; and mucous disease, in which it is intense. 

HABITUAL INDIGESTK )N. 

In the rare cases of this disease where death has resulted 
from an intercurrent affection, post-mortem examination has 
revealed the gastro-intestinal mucous membrane finely injected, 
reddened in patches, flabby, swollen, and covered with a layer 
of tenacious mucus of variable thickness. In the majority 
of cases, though, it is probable that the catarrh does not 
extend beyond the grade that would leave no gross change 
after death. 

Etiology. — The predisposing agencies are deficient func- 
tional activity of the stomach, either existing simply as a factor 
of a weak constitution, or resulting from previous disease or 
ill-directed hand-feeding. Residence in large cities, and in 
close, damp houses ; too little outdoor exercise, and too 
much confinement and pushing at school, belong to this class 
of causes. The}' all act by lowering the capacity to digest, 
and the best food imperfectly digested undergoes chemical 
changes rendering it irritant and capable of transforming the 
normal hyperaemia of digestion into the congestion of catarrh. 
Fewer cases are met with in summer than in winter, because 
children live more out of doors, and the functions of the 
skin are more active, keeping a larger quantity of blood at 
the surface — a great safeguard against catarrh. Season, then, 
may be added to the predisposing influences. 



2 54 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

The prime exciting cause is unsuitable food. As a rule, 
especially with children of the poorer classes, among whom 
the disease is very rife, the fault lies in the food being too 
strong. These children are allowed to sit at table and partake 
of whatever the elders eat, such as meat two or three times a 
day, with potatoes, bread and butter and tea, none too well 
prepared or of too good quality. This coarse food, of itself 
irritating to the delicate lining of the stomach, is also very 
difficult to digest. The child may have force enough to main- 
tain a fair degree of health against this odds for a while, and 
some even win in the race, but for most, the time of trouble 
surely and soon comes. Some portions of the food begin to 
escape, more or less completely, the solvent action of the 
gastric juice. The starches and fats, influenced by the heat 
of the parts and the organic matter or bacteria present, undergo 
fermentation, and are converted into acids, with the liberation of 
carbonic acid gas ; the albuminoids become partially decom- 
posed and acrid. These not only irritate the mucous lining 
of the stomach, but, passing into the intestine, act upon its 
mucous membrane, and cause the same catarrhal lesions there. 

At first an attack of vomiting and purging, by cleaning out 
the alimentary canal, puts an end to the catarrh, and the 
patient is free from symptoms so long as the resulting anorexia 
restricts his appetite. But a return to the old diet is quickly 
followed by a relapse, culminating in another natural effort at 
relief; and so the attacks recur, growing more and more fre- 
quent and easily induced, until what was originally an acute 
and passing indigestion becomes chronic. 

As soon as the catarrh is established and the interior of the 
canal is covered with tenacious mucus, the disease begins to 
react upon and increase itself. For, whatever food is taken is 
soon enveloped by mucus, and this coating prevents the free 
access of the gastric and intestinal juices, which are solvents 
and antiferments. Mucus, too, is in itself a powerful ferment, 



AFFECTIONS OF THE STOMACH AND INTESTINES. 255 

and increases the formation of irritating substances ; further, 
by covering the interior of the alimentary canal, it prevents 
the absorption of what little food is digested, leading to mal- 
nutrition, with a deterioration in the quality of the gastric 
juice and succus entericus, and leaving more material for 
chemical change. Thus there is a direct and an indirect reac- 
tion. 

Well-to-do children are spared a coarse diet and, in conse- 
quence, do not suffer so severely. In them bad food takes 
the form of rich dishes, pastry, sweets, and so forth. 

Exposure to wet and cold has some excitant influence, 
though, without the aid of bad diet, it is scarcely sufficient to 
induce an attack. 

Symptoms. — When the disease is fully developed, the pa- 
tient has a spare, delicate appearance, the face wears a languid 
expression and is pale ; the pallor at intervals increasing very 
much, or again giving place to flushing of one or both cheeks. 
The hair is crisp and lustreless. The conjunctivae are some- 
times natural, but more often slightly yellow. The skin is 
cool, dry and rough to the touch, and somewhat sallow in 
hue. The pulse is weak,, but otherwise unaltered. The mu- 
cous membrane of the mouth is less pink than normal ; the 
breath has a heavy, disagreeable odor ; the tongue is pale, 
broad, and flabby, frequently indented by the teeth, and cov- 
ered with a thin, white frosting, which grows thicker, and more 
yellowish toward the posterior part of the dorsum. Through 
this coating the enlarged fungiform papillae project, and are 
redder than the rest of the mucous membrane, but not so 
highly colored as in acute gastric catarrh. Moderate hyper- 
trophy of the tonsils can frequently be observed, and, as a 
rule, the cervical lymphatic glands are slightly enlarged. 

The appetite is variable and perverted, the desire being for 
highly seasoned food. After eating, eructations of flatus 
occur, and small quantities of partially digested food, mixed 



256 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

with thin mucus and intensely sour, are from time to time re- 
gurgitated from the stomach. Tympanites is a constant 
symptom, and when the child is stripped the distended abdo- 
men contrasts markedly with the spare trunk and limbs. 
Pain is uniformly present. It maybe constant or paroxysmal, 
severe and colicky, or only amounting to discomfort, and 
either general or confined to certain parts of the abdomen. 
Usually it is paroxysmal, beginning from two to three hours 
after meals ; if constant, it is subject to exacerbations at these 
periods. Generally, too, it is only moderately severe, and is 
confined to the left or right hypochondriac region ; the rea- 
son for this limitation being, that in both positions, but espe- 
cially in the first, the colon makes a sharp turn, where the 
gases, liberated by fermentation, become lodged. On account 
of the mucus covering the faecal masses as well as the interior 
of the bowel, bringing two slippery surfaces together, the 
peristaltic contractions are less efficacious, and constipation 
results. Intervals of two, three, or even nine days elapse 
between the movements, which are attended by considerable 
straining, and result in the expulsion of a small number of 
dark, hard lumps enveloped in mucus. 

The urine, at times, is scanty and high-colored ; at others, 
overabundant and light-colored. The diminution is apt to 
attend exacerbations of abdominal pain. 

During the day the child is listless, disinclined to play, and 
easily tired, while at night he tosses about the bed in a dreamy 
sleep. 

To the above symptoms catarrh of the nasal and bronchial 
mucous membranes is often added. 

It is usual for the even course of the disease to be broken 
by vomiting and diarrhoea. In such attacks there may be 
slight fever, the tongue becomes more heavily coated, the ap- 
petite fails and thirst is increased. The vomited matter at first 
is composed of acid, partially digested food, mixed with stringy 



AFFECTIONS OF THE STOMACH AND INTESTINES. 257 

mucus ; afterward, if there be much retching, of more or less 
bile-stained mucus alone. The purging, primarily, unloads 
the bowel of a large quantity of lumpy faeces, apparently the 
collection of several days ; afterward, the stools are made up 
of mucus and liquid faeces. Such attacks last one or two days, 
and are followed by a brief period of improvement. 

The diagnosis is easy. 

The prognosis is favorable, though when left to itself the 
disease runs a protracted course, improving in summer to re- 
turn in winter. By the general debility that it produces, it 
opens the way to intercurrent affections, or the development 
of hereditary tendencies, and renders both more fatal. 

MUCOUS DISEASE. 

This form of chronic gastro-intestinal catarrh occurs much 
less frequently than the other. It consists of a mucous flux 
from the whole internal surface of the alimentary canal, which 
interferes mechanically with the digestion and absorption of 
food, and so impedes nutrition as to suggest the presence of 
tubercles. The lesions are identical in kind with those of 
habitual indigestion, but are much greater in degree. 

Etiology. — The affection usually arises between the fourth 
and twelfth years, and has the same predisposing and exciting 
causes as the milder form. It is also a frequent sequel of 
pertussis. 

During the course of whooping-cough the gastro-intestinal 
mucous membrane is always in a catarrhal state. Much of 
the tenacious mucus expelled at the end of each paroxysm 
comes from the stomach. When vomiting occurs, most of 
the matter ejected is mucus, and the stools contain a quantity 
of the same substance. As the cough subsides, the secondary 
catarrh usually disappears, but after severe attacks, and in 
feeble children, it may continue, and pass into mucous dis- 
ease. 

22 



258 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Symptoms. — As might be expected from what has already 
been said in regard to lesions and causation, the symptoms, in 
the main, are those of habitual indigestion greatly magnified, 
and to these are added certain well-defined nervous manifes- 
tations. 

The child is emaciated and muscularly weak. His face is 
uniformly pale, though subject to great changes in color, and 
at times a circumscribed crimson flush appears on one or both 
cheeks ; at others, there is so much pallor, especially about 
the lips, that fainting seems imminent, and, indeed, it does 
sometimes occur. The eyes are surrounded by bluish circles, 
which deepen when the face pales. The conjunctivae are 
muddy, and there is occasional squinting. The skin is mark- 
edly sallow, dry and rough to the touch and, by light friction, 
numerous fine scales of dead epidermis can be removed, and 
the hair has a lustreless, faded appearance. The cervical 
lymphatics are noticeably swollen, though painless. 

The oral mucous membrane is pale. The tongue, besides 
being flabby and indented by the teeth, presents an appearance 
characteristic of the disease. The dorsum, with the exception 
of an oval space in the centre, is covered with a light gray 
coating, scarcely thick enough to obscure the natural pale-pink 
color, and shows clearly the slightly redder fungiform papillae. 
The oval bare spot, about as large as a cent, is still deeper 
red, and shines as though varnished. This glossy look, in 
very severe cases, extends over the whole dorsum, and is due 
to an excessive secretion from the mucous glands of the 
mouth. Such a tongue does not lose the natural velvety 
appearance arising from the fungiform papillae. (See a, 
Plate 11.) 

Chronic hypertrophy of the tonsils, with plugging of the 
follicles by retained secretion, is common, and in part accounts 
for the disagreeable odor of the breath. 

The appetite in the beginning fails, then becomes capricious, 



AFFECTIONS OF THE STOMACH AND INTESTINES. 259 

and, finally, almost insatiable. The increased desire for food 
is due partly to a morbid craving, excited by the irritation of 
the fermenting contents of the stomach and intestines, and 
partly to the demand of the tissues generally for more nutri- 
ment than is supplied by the imperfect digestion and impeded 
absorption. Eating is followed by a sensation of drowsiness, 
and by eructations of flatus and acid liquid. 

Tympanitic distention of the belly is always marked, and 
the child complains of pain in this portion of the body. The 
pain may be general, amounting to little more than a sen- 
sation of soreness, but more frequently it is limited to the 
left hypochondrium, and is stitch-like in character. Either 
variety may be constant, or present only after meals ; in the 
former case there is a temporary increase of discomfort after 
eating. In some instances paroxysms of severe pain in the 
neighborhood of the umbilicus occur early in the morning, 
and occasionally after meals. These are unattended by 
nausea, purging, or doubling of the body to secure relief, as 
in colic, but while they last the pallor of the face is extreme. 

Constipation is the usual condition of the bowels. Evacu- 
ations take place at intervals of several days, with much strain- 
ing, and at times rectal prolapse ; they are scanty, and com- 
posed of small, hard, dark-colored lumps with a large pro- 
portion of mucus, and often contain intestinal parasites or 
their ova. Sometimes the constipation lasts for a week or 
more at a time, to be followed by a number of free evacuations 
in quick succession, relieving the bowel of the accumulated 
faeces ; then comes another period of confinement, another 
relief, and so on. 

By day, the patient suffers from headache ; is languid, ill 
tempered, and disinclined for study or play. At night, he is 
restless ; grinds his teeth ; starts from sleep in terror caused 
by frightful dreams, and often screams or talks incoherently, 
and for a time is seemingly unconscious of his surroundings. 



26o DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Somnambulism and nocturnal incontinence of urine are quite 
common. Stammering is another nervous symptom occasion- 
ally encountered. 

There is no alteration in the temperature ; the pulse is feeble, 
and there is frequently a slight, dry, hacking cough, entirely 
independent of pulmonary disease. The urine is diminished 
during the continuance of severe pain, but is voided in exces- 
sive quantities at the termination of the paroxysms. 

At intervals of two or three weeks violent vomiting and 
purging occur. During these attacks, which last from one to 
three days, a large quantity of mucus is rejected ; there is 
slight fever, and the tongue is changed in appearance, and for 
the second time assumes a characteristic aspect. It becomes 
less flabby, more pointed, and covered with a thick, white, 
feathery fur, except along the sides, where there are several 
smooth, bright-red, glazed patches of variable size and shape, 
with irregular, indented edges. A few red fungiform papillae 
show through the coating. Sometimes the whole dorsum is 
clean, red, and glazed, as if denuded of epithelium. (See b> 
Plate ii.) Temporary improvement follows the clearing-out 
process, but soon the symptoms return, and slowly grow 
worse, to culminate in another attack. 

The course of the disease is very chronic, extending over 
months. There is no regular progression, though the ten- 
dency is for the symptoms to grow more and more severe as 
time elapses. 

Diagnosis. — Tuberculosis is the condition most likely to 
be confounded with the disease in question, and the mistake 
is especially apt to be made when a dry, hacking cough is 
present. The appearance of the symptoms after whooping- 
cough ; the state of the tongue ; the mucous stools ; the con- 
dition and color of the skin ; the absence of pyrexia except 
during the attacks of vomiting and purging ; the periodicity 
of these attacks ; the diurnal drowsiness and nocturnal terrors, 



AFFECTIONS OF THE STOMACH AND INTESTINES. 26 1 

and the irregularity in the course are the distinguishing fea- 
tures. 

Prognosis. — Mucous disease is not in itself mortal, and is 
perfectly amenable to treatment. It is, nevertheless, dangerous 
from its power to reduce the general nutrition, thus opening 
the way for more serious intercurrent affections. 

As the plan of managing both forms of chronic gastrointes- 
tinal catarrh is the same, it is unnecessary to divide the sub- 
ject of — 

Treatment. — Since the exciting cause is perfectly well 
known and removable, relief may be confidently promised, 
provided it be possible to regulate the diet. There are two 
rules to be insisted upon : first, to stop the supply of all those 
articles of food that readily undergo fermentation ; and, second, 
to allow only a moderate quantity of food at a time, so as not 
to overdistend the stomach, while the meals are increased to 
four a day, to insure the ingestion of a proper amount of 
nourishment. 

All farinaceous substances must be excluded from the diet- 
ary save stale or toasted bread, and this, even, must be restricted 
in amount. Potatoes, peas, beans, turnips, carrots, parsnips, 
fruit, cakes, pastry, sweetmeats, and butter are all in the pro- 
scribed list. 

Of permissible articles, milk, eggs, and lean meat are the 
chief, though poultry, game, fresh fish, raw oysters, cauli- 
flower tops, spinach, asparagus, lettuce, and celery can be used 
without ill effect. 

With such food to select from, it is easy to write out a 
suitable diet list and make changes sufficiently often to 
avoid cloying the appetite by monotony. In writing such 
lists, it is best to fix the hour, as well as the ingredients, 
of each meal. For example : 

Breakfast, at 7 A. m. — One or two tumblerfuls of milk 



262 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

guarded by lime water* (fgij to f.Syj), the yelk of a 
soft-boiled egg, and a single thin slice of stale, unbuttered 
bread. 

Luncheon, at 1 1 a. m. — A cup (fgiv) of beef-, chicken-, or 
mutton-broth, entirely free from fat,f and a thin slice of dry 
toast. 

Dinner, at 2.30 p. m. — Broiled mutton chop, entirely free 
from fat, one or two, according to the size ; a large spoonful 
of well-boiled spinach, and a slice of stale, dry bread. 

Supper, at 7 p. m. — One or two tumblerfuls of milk guarded 
by lime water, and a slice of dry toast. 

Filtered water must constitute the drink, though, if the child 
will take it, half a tumblerful of Vichy at luncheon and dinner 
can be recommended. 

Should failing appetite demand a change, another menu must 
be made, as : 

Breakfast. — Milk, a bit of boiled fresh fish, and a thin slice 
of unbuttered toast. 

Luncheon. — The soft parts of six or eight small oysters, 
seasoned with salt alone, and a Boston cracker. 

Dinner. — A bit of the breast of a roasted or boiled fowl, a 
moderate portion of well-boiled cauliflower tops, and a slice 
of stale, dry bread. 

Supper. — Milk and dry bread. 

Further variety can be had by substituting a thin slice of 
cold roast mutton or beef for the egg or fish at breakfast ; at 
dinner, by running the changes on roast mutton, broiled beef- 
steak, roast beef, plainly cooked game, and such vegetables as 
stewed celery, boiled asparagus tops, spinach, and cauliflower ; 

* The lime water is added both for the purpose of retarding coagulation and for 
its effect upon the mucus in the alimentary canal. 

| The fat can be completely removed by allowing the broth to stand for a few 
minutes after it is made, and picking off the globules of oil as they rise to the 
surface with a fragment of blotting-paper. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 263 

by using different sorts of meat broths, and by changing the 
manner of cooking the eggs. 

When, in mucous disease, there is great debility, stimulants 
are indicated. They should be given well diluted and with the 
meals. Whiskey and old dry sherry are the best. Of the 
first, one or two teaspoonfuls in a fourth of a tumbler of 
water may be given with lunch and dinner ; of the second, one 
or two tablespoonfuls with twice as much water at the same 
meals. 

Next to regulating the diet it is important to maintain the 
activity of the skin. This is to be accomplished by baths, 
inunctions, and proper clothing. Each morning the patient, 
being in a warm room, and standing in enough hot water to 
cover the feet, should be sponged with water at a temperature 
of yo° F., then thoroughly rubbed down with a coarse towel, 
and the whole body anointed with warm olive oil, which ought 
to be gently rubbed into the skin with the finger pulps. At 
bedtime a full bath of ioo°, of five minutes' duration, must be 
given, and the inunction repeated, after careful drying with 
friction. In severe cases, where the skin is very dry and rough, 
the first warm bath should contain a heaped teaspoonful of 
soda, and with this and soap the whole surface must be thor- 
oughly scrubbed. 

Woolen underclothing, to cover completely the trunk and 
limbs, and woolen stockings are to be insisted upon. The 
weight may be changed with the weather, but not the material. 
This not only keeps the skin warm, full of blood, and func- 
tionally active, but it also maintains the heat of the whole 
body and saves force. Children dressed for beauty with four 
or five inches of bare leg, nine times out of ten suffer from 
chronic indigestion or bronchitis. First, because chilling of 
the surface drives the blood toward the interior and puts 
the mucous membranes in the most favorable condition for 
catarrh ; secondly, because so much force is consumed in 



264 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

maintaining the normal temperature, in the face of constant 
chilling, that other functions, notably the digestive, must suffer. 
Parents would appreciate this better if they could be persuaded 
to try the experiment of sitting, for an hour or so, even in a 
warm room, in the same degree of nakedness that they inflict 
on their children, who are less robust and less able to resist 
cold. 

Exercise in the open air on suitable days in winter, and an 
almost complete outdoor life in summer, hastens recovery. 
The sleeping and living rooms should be large, light, dry, 
well ventilated, and properly warmed. 

Medicinal treatment is of minor importance, but by no means 
to be neglected. The indications to be fulfilled are to check 
the secretion of mucus ; to neutralize the acids formed by 
fermentation of the food ; to restore the mucous membrane to 
a normal condition, thereby improving secretion, digestion, 
and appetite, and to secure regular action of the bowels and 
the expulsion of collected mucus and faeces. These accom- 
plished, strength and health return, though it may be necessary 
to call in the aid of tonics. 

Alkalies are the best remedies to check the secretion of 
mucus, and to liquefy it so that it may more readily be re- 
moved. They are also most efficient in neutralizing the acid 
products of fermentation. Simple bitters, too, have some 
power in lessening the formation of mucus, and considerable 
influence in arresting fermentation ; at the same time they give 
tone to the mucous membrane and stimulate digestion. Lax- 
atives keep the bowels clear. Of the first class, bicarbonate 
of sodium, phosphate of sodium, and chloride of ammonium ; 
of the second, gentian, calumba, nux vomica ; and of the 
third, senna or aloes, are to be preferred in treating this dis- 
ease. 

In habitual indigestion a combination like the following will 
be all that is required : 



AFFECTIONS OF THE STOMACH AND INTESTINES. 265 

U . Sodii bicarbonatis, 3 i j 

Ext. senna? fluid., fo"J 

Inf. gentiana? comp., q. s. adf^iij. M. 

SiG. — Two teaspoonfuls three times daily before eating, at the age of seven 
years.* 

Should there be yellowness of the conjunctivae and marked 
sallowness of the skin, indicating a slight degree of catarrhal 
jaundice, it is well, at first, to substitute equal doses of chlo- 
ride of ammonium for the bicarbonate of sodium in this pre- 
scription. 

In mucous disease a similar prescription, with minute doses 
of iodide of potassium to increase the salivary secretion, may 
be ordered before meals, as : 

R . Potassii iodidi, gr. vj 

Sodii bicarbonatis, 5jj 

Ext. senna? fid., f^iij 

Inf. calumbre, q. s. ad f^iij. M. 

SiG. — Two teaspoonfuls three times daily before eating. 

After food, it is well to order from ten to twenty drops of 
tincture of myrrh in a little water, for its powerful tonic action 
on the intestinal mucous membrane. 

Aloes is valuable not alone as a laxative, but in arresting 
the mucous flux and bracing the mucous membrane. It can 
be administered in the form of tincture of aloes and myrrh, in 
doses of twenty drops, three times daily after eating. Or, if 
the child be able to swallow a pill, it may be combined thus : 

li . Pulv. ipecacuanha?, gr. j 

Pil. aloes et myrrhae, gr. xij 

Ext. gentians, gr. vj 

Ext. taraxaci, gr. xij. , 

M. et ft. pil. No. xij. 
SiG. — One pill three times daily an hour after eating. 

When there is much debility, iron is demanded ; and if the 



All of the subjoined prescriptions are proportioned for children of this age. 



266 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

proper form be selected, it may be given in spite of a coated 
tongue, the usual contraindication. A good formula is : 

U • Ferri sulphatis exsiccati, gr. xij 

Tr. aloes et myrrhse, f£p v 

Syr. rhei aromat., q. s. ad f^iij. M. 

Sig. — One teaspoonful three times daily after meals. 

From this prescription there is an astringent action, by the 
iron and rhubarb, which tends to check the formation of 
mucus ; a laxative action, by the aloes and rhubarb, keeping 
the bowels clear of mucus and faeces ; while the myrrh is a 
direct tonic to the relaxed mucous membrane. 

If, as the tongue cleans, the improvement under this plan 
comes to a stand, it is advisable to change to an acid treat- 
ment. There are several useful prescriptions, for instance : 

K: . Tr. nucis vom., ttVxxxvj 

Essence of pepsin (Fairchild's), f 5 vj 

Acidi muriaticidil., f^ij 

Elix. aromat., q. s adf^iij. M. 

SiG. — One teaspoonful three times daily after eating. 

Or an acid may be combined with a bitter : 

R. Acidi nitro-muriat. dil., f^j 

Inf. gentianas comp., q. s. ad f.^iij. M. 

SiG. — One teaspoonful three times daily after meals. 

Or— 

R. Quininoe sulphatis, gr. xij 

Acidi muriatici dil., f ^ ij 

Aquoe cinnamomi, . q. s. adf^iij. M. 

SiG. — One teaspoonful three times daily after meals. 

All of these prescriptions must be well diluted and taken 
through a glass tube. 

During the periodical attacks of vomiting and diarrhoea, so 
apt to occur in both forms of the disease, the child must be 
put to bed, restricted to a diet of milk and meat broths, given 
a course of calomel in minute doses, — gr. -J4 to y 1 ^- with gr. j 
of bicarbonate of sodium every hour for six doses, — and then 
the following prescription : 



AFFECTIONS 7 THE STOMACH AND INTESTINES 267 

zx :: .--.-. 7 ::.:.':..'. :• " -•- 

Sodii bicarbonatis. =u 

77.-. i::m::;: rr :-.:; 

ML et ft. chart No. xq. 

Sic — One powder four times dairy. 

The diarrhoea must not be interfered with unless it become 
exce hen it may be held under control by adding five 

grains ::" sab turbinate :: bisrnurb :: ea:b :: the alkaline 
powder s 

After the tongue becomes normal and the active symptoms 
have disappeared, the general strength must be built up by a 
course of tonics. The best are tincture of mix : mica, ferrated 
elixir of cinchona, and bitter wine of iron. In order to prevent 
a relapse, a mixed diet must be avoided for at least two months 
after convalescence is fully established, and to confirm the 
cure, change of air, by a trip to the sea- shore or mountains is 



Both habitual indigestion and mucous disease are occasion- 
. attended by a troubles :::.e symptom that demands brief 
consideration. This s a peculiar cough, which is dry, par:x- 
ysmal, and unattended by lesi ns of the throat or lungs. The 
paroxysms are due to reflex aauses they rommence in the 
early evening, and may by their repetition, prevent sleep for 
half the night. On the following day the patient is as til as 
usual, or coughs only at long intervals, but about bedtime 
the trouble begins again. So the symptom continues for 
weeks at a time, unless its true nature as a stomach cough " 
be recognized and it is properly treated. The paroxysms 
suggest those of pertussis tbough they may be distinguished 
the ah sen :e of whooping, and of the character istic expulsion 
of tenacious mucus at the end of the kinks. Questioning 
often reveals the fact that the cough is rse purer a rich and 
heavy supper. 



268 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

If proper clothing be worn, the diet carefully regulated, and 
alkalies prescribed, as for an ordinary case of chronic gastro- 
intestinal catarrh, improvement is rapid, for in this way the 
cause is removed. Ordinary cough mixtures do more harm 
than good, from their tendency to derange digestion ; still, the 
fatiguing cough must be relieved. This can be done by letting 
the child wear a small bean-shaped belladonna plaster over the 
larynx, and administering a dose of one of the following mix- 
tures every two hours, beginning at four o'clock in the after- 
noon : 

K • Pulv. aluminis, gr. xlviij 

Potassii bromidi, g ij 

Syrupi zingiberis, 

Aquae, aafgiss. M. 

SiG. — Dose, one teaspoonful. 

Or— 

R . Ext. belladonnas, gr. ss-j 

Pulv. aluminis, gr. xlviij 

Syrupi zingiberis, • 

Aquae, aa f^iss. M. 

SiG. — Dose, one teaspoonful. 



ACUTE INTESTINAL CATARRH (SIMPLE DIAR- 

RHCEA). 

The condition intended to be indicated by this title is usually 
called simple or non-inflammatory diarrhoea, and classed as a 
functional disease. But from its etiology, and from the fact 
that in certain patients and under certain circumstances it so 
readily lapses into entero-colitis, it is more than probable that 
it depends upon a distinct, though passing lesion — a hyper- 
emia or catarrh of the intestinal mucous membrane. This is 
difficult to demonstrate, partly because the opportunity for 
post-mortem inspection is rare in simple diarrhoea, and also on 
account of the well-recognized rapidity with which the appre- 



AFFECTIONS OF THE STOMACH AND INTESTINES. 269 

ciable manifestations of mild forms of catarrh disappear after 
death. Nevertheless, even those authors who advocate the 
functional character of the affection, state that in some instances 
of death, in feeble children or from intercurrent disease, 
autopsy shows injection, swelling, and relaxation of the 
mucous membrane, and tumefaction of the intestinal glands. 

Etiology. — Constitutional feebleness and unfavorable hy- 
gienic surroundings, especially residence in crowded, damp, 
and filthy houses and quarters of cities, increase the liability to 
attacks of diarrhoea. Many more cases occur in summer than 
at other seasons of the year. Children of either sex, or of any 
age, may be affected, though the younger the patient, the more 
serious the disease. 

In infancy there are numerous exciting causes. Overfeeding, 
even with healthy breast milk or well-prepared cows' milk, is 
one. Ordinarily in such cases vomiting is so easy that the 
child gets rid of the surplus and no harm is done ; but if this 
does not happen, the excess remains undigested, undergoes 
change, acts as an irritant to the intestinal mucous membrane, 
and causes diarrhoea. Another cause is food of bad quality : 
either poor and cholesterin-laden breast milk, or unsound bac- 
teria-laden cows' milk and farinaceous preparations. Here the 
action is the same as in overfeeding, though more rapid and 
violent ; this is especially true of the farinacese, on account 
of their readiness to undergo acid fermentation. Again, ex- 
posure to cold and wet, by chilling the surface and determining 
the blood to the interior of the body and mucous membranes, 
may lead to an intestinal catarrh, in the same way that it does, 
more frequently, to a bronchial catarrh. Hyperemia, too, 
of the mucous membrane of the alimentary tract is attended 
by a diminution in the secretion of digestive solvents and an 
increased production of the mucus — two conditions most 
favorable to incomplete digestion and fermentation of the food 
with the formation of irritant products. These, as already 



270 DISEASES QF DIGESTIVE ORGANS IN CHILDREN. 

seen, are quite capable, in themselves, of causing looseness of 
the bowels, and must greatly add to the ill effects of exposure. 
High atmospheric temperature is much more influential than 
low, particularly when associated with excessive moisture. 
Such conditions are powerful depressants to the vital forces ; 
the digestion shares in the general weakness, and much of the 
food is left to ferment and become irritant, and carelessly kept 
food is more apt to become changed and to be rendered injuri- 
ous by bacterial influences. 

During childhood the chief exciting cause is still the use of 
unsuitable food. 

It is almost unnecessary to call attention to the lesson taught 
by this study of the etiology. There is, on the one hand, the 
presence of an irritant as a constant factor ; on the other, a 
mucous membrane naturally delicate and functionally very 
active. The conclusion is inevitable, that the ordinary effect 
must follow, and hyperemia or catarrh be produced. 

Symptoms. — In infants the attack may begin suddenly, or 
be preceded for twenty-four hours or more by peevishness, 
languor, faded cheeks, slight abdominal pain, indicated by 
moaning or fits of crying, and restless, disturbed sleep. 

Next, the bowels become disturbed. The movements num- 
ber from four to eight in twenty-four hours, and usually occur 
only while food is being taken — from six in the morning to ten 
o'clock at night. At first they differ from the normal merely 
in being more liquid and copious, and having a more offen- 
sive odor. As the disease progresses they undergo various 
changes. Sometimes they are composed of a yellowish liquid 
containing white or yellowish flakes resembling curdled milk. 
At others, distinct white lumps of undigested curd are mixed 
with the liquid. Still again, green flakes may appear in a 
stool having the characters of the first ; and, finally, the whole 
may be of a deep green color, and contain small masses of 
mucus. In exceptional cases a small amount of bright-colored 



AFFECTIONS OF THE STOMACH AND INTESTINES. 2J \ 

blood may be seen in the evacuations. Often the movements 

are preceded, for a short time, by pain, but this disappears as 
soon as the act is accomplished. Occasionally, if the stools 
be acid, considerable tenesmus attends their expulsion, and it 
is under such circumstances that blood is most likely to be 
voided. 

The tongue is lightly coated ; there is anorexia, increased 
thirst, and occasionally nausea and vomiting. The abdomen 
is natural in shape, and is soft and painless on palpation. The 
urine is somewhat lessened in quantity, and high-colored. 
There is no pyrexia, and the pulse is but slightly increased in 
frequency. 

The evil effect of several days' continuance of diarrhoea upon 
the general condition of the child is shown by the pallor of the 
face, the sunken eyes, the loss of weight, and the flabbiness of 
the muscles. Under proper management the attack terminates 
in from four to seven days, and strength is soon restored. 

Simple diarrhoea is more uncommon in older children and 
much milder in its manifestation. There is slight furring of 
the tongue, loss of appetite, and abdominal pain of a colicky 
nature, with more or less frequent evacuations of light yellow, 
offensive, semi-solid or liquid faecal matter, at times containing 
masses of partially digested food. The patient is weak and 
disinclined to exert himself. These attacks last for three or 
four days, and are followed by little constitutional depression. 

Diagnosis. — There is no difficulty in distinguishing the 
disease. The only conditions for which it could possibly be 
mistaken are tuberculous diarrhoea and entero-colitis. The 
former is excluded by the history and course of the case and 
by lack of evidence of tuberculosis of other portions of the 
body ; the latter, by the apyrexia and the non-existence of 
symptoms indicating intestinaHnflammation. 

Prognosis. — The result of even the more serious attacks 
in infants is, in the great majority of cases, favorable ; never- 



272 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

theless, it must not be forgotten that an acute catarrhal diar- 
rhoea, when it occurs in a weak, ill-fed, and badly cared-for 
child during hot weather, has a tendency to run into entero- 
colitis, and thus prove fatal. An infant, too, may be so debili- 
tated by previous illness as to be carried off by an attack of 
ordinary severity. 

Treatment. — Before entering into the details of the manage- 
ment of this disease, it is necessary to draw attention to the 
conservative nature of the diarrhoea. The frequent, loose, 
and copious stools clear the intestines of irritant matter, and 
remove the cause of further trouble. Consequently, it is 
never advisable, early in the course, to completely arrest the 
evacuations, although at the same time they must be kept 
well in hand, lest the attack pass into entero-colitis. 

As in other digestive disorders, the most essential step is to 
attend to the feeding. With infants nursed at a healthy breast 
it is enough to see that they are not fed too frequently, and to 
lessen the quantity taken by shortening each act of sucking. 
If, from any cause, the breast milk be unsuitable, the babe 
must be weaned and carefully fed by bottle. In hand-fed 
babies it is necessary, first, to insist upon the use of the old- 
fashioned bottle and tip, and to see that they are kept abso- 
lutely clean. Next, to banish all farinaceous preparations, 
used purely as foods, from the diet. This does not preclude 
the employment of small quantities of barley water or rice 
water for the purpose of breaking up the milk curd. Thirdly, 
to direct that the daily supply of milk — the only food to be 
allowed — must come from one reliable dairy ; be received 
fresh in the morning, and kept in separate, perfectly clean 
vessels, and, if possible, in an especial refrigerator. And, 
finally, to give careful, written orders as to the manner of pre- 
paring the milk food, and to make a rule that each bottle shall 
be mixed separately and only immediately before it is required. 
In hot weather, and especially in cities, it is advisable to 



AFFECTIONS OF THE STOMACH AND INTESTINES. 



/ 



Pasteurize the whole supply of milk immediately after it is 
received in the morning, but this does not affect the principle 
of the separate preparation of each portion. 

As guides to the manner of modifying the milk, two formulae 
may be given ; they are proportioned for children of four to 
six months : 

Unskimmed milk, ^3 ns5 

Cream. fo ss 

Lime water, f^ij 

Sugar of milk, gj. 

Mix these in a clean bottle, and warm by standing in hot 
water. Five to six bottles to be taken during the day. 



O 



Unskimmed milk, f3 nss 

Cream, f.o 5S 

Rice water,* f^ij 

Sugar of milk, g]. 

Mix and treat as before. 

The quantity is to be reduced and the dilution increased in 
proportion to the youth of the infant, and the reverse as age 
increases. Sometimes in children of one or two months a 
cream and whey mixture suits better, as : 

Fresh cream, fo 5S 

Whey, : f 3 iss 

Hot water, fo* 55 

Sugar of milk, ^ j. 

If the simple milk mixtures be imperfectly digested and the 
casein appears as curds in the faeces, partial predigestion with 
peptogenic milk powder must be resorted to. 

When there is thirst, cool water should be given with 
moderate freedom. 



* Rice water. — Put two teaspoonfuls of washed rice in a saucepan with a pint 
of water; boil slowly down to two-thirds of a pint; strain. 
23 



274 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

The sleeping room should be airy, well ventilated, and, in 
hot weather, the coolest the house affords. Soiled diapers, or 
the vessel containing a stool, must not be left about. In 
summer the patient should pass the mornings and evenings in 
the open air, and the hot mid-day in a cool room. A day's 
excursion on a steamboat, or to the country, if the journey be 
short, is very beneficial, while a trip to the sea-shore works 
wonders ; a single day passed in salt air often removing every 
trace of the disease. Even in winter, if an attack occurs, the 
child, well wrapped up, should be taken out for an hour at 
noon on warm, sunny, still days. 

The daily bath must be continued, and in hot weather a 
bath morning and evening is none too much. Woolen draw- 
ers and shirts of the lightest texture must be worn in summer, 
and if the diarrhoea prove at all obstinate, the abdomen must 
be enveloped in a light flannel bandage. 

When these measures are carefully carried out in mild cases, 
medicines are often unnecessary. In those more severe, it is 
well to assist nature and begin the treatment with a laxative. 
Pain, green stools, and the presence of blood always indicate 
this course. The best laxative is castor oil. This not only 
efficiently clears away the irritating contents of the intestines, 
but has a secondary, soothing action upon the mucous mem- 
brane. For a child of six months, the dose is a teaspoonful, 
with five drops of camphorated tincture of opium to prevent 
griping. 

After this has operated, a teaspoonful of chalk mixture 
every two hours will complete the cure in some instances. 
A more efficient prescription, however, is : 

$ . Sodii bicarbonatis, ^ss 

Syrupi rhei aromat. , f,! ss 

Aquse menthre pip., q. s. adf^iij. M. 

Sig. — Teaspoonful every two hours. 

The great value of rhubarb depends upon its combined 



AFFECTIONS OF THE STOMACH AND INTESTINES. 275 

laxative and astringent action, precisely what is required in 
simple diarrhoea. 

Should the stools still fail to become less frequent and more 
natural in color and consistence, resort must be made to 
astringents. A very good formula is : 

B. Syr. rhei aromat, f 3 j 

Bismuth, subcarb. (Squibb), gr. lxxij 

Syrupi, f£ ss 

Misturae cretae, q. s. adf^iij. M. 

SlG. — Teaspoonful every two hours. 

The value of calomel in certain cases where the evacuations 
obstinately remain green and acrid must not be overlooked. 
It must be employed in small doses, and combined with an 
alkali; thus : 

R . Hydrargyri chloridi mitis, gr. j 

Cretae praeparatae, gr. xxiv. 

M. et ft. chart. No. xij. 
SlG. — One powder every two hours. 

Its good effect should be noted in twenty-four hours ; then it 
must be discontinued, and one of the other prescriptions given. 

When the stools become normal, tincture of nux vomica 
and essence of pepsin must be ordered for a week or more 
until the digestion is put upon a sound footing. 

In older children the treatment is very simple. All that is 
required is a bland diet, perhaps a dose of castor oil, and some 
mild astringent mixture. For example, let the patient take 
for breakfast — a soft-boiled egg, milk guarded with lime- 
water, and stale, dry bread ; for dinner — some meat broth, 
free from fat, with stale, dry bread, and rice-and-milk pudding ; 
and for supper — milk, and stale, dry bread. The bismuth 
mixture already given, increased in dose proportionately to the 
age, is very serviceable. As with infants, a course of essence 
of pepsin, or pepsin with muriatic acid and tincture of nux 
vomica or other bitter tonic, should terminate the treatment. 



276 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

CHRONIC INTESTINAL CATARRH. 

Chronic entero-colitis, or chronic diarrhoea, as this con- 
dition is frequently termed, is a common and fatal disease in 
infants. When it occurs after the completion of the first denti- 
tion, it is less dangerous to life, though it runs a protracted 
course and interferes greatly with nutrition. 

Morbid Anatomy. — As with other catarrhs, the absence of 
appreciable lesions is quite possible ; but usually the mucous 
membrane of the colon is studded with minute, dark spots — 
the shaven-beard appearance — which the microscope shows 
to depend upon rings of vascular injection around the orifices 
of the follicles. In some instances there is deep congestion, 
limited principally to the summits of the longitudinal plicae, 
while in others ulcers are also found. These ulcers are shal- 
low, and either elongated and narrow, when they occupy the 
summits of the plicae, or small and circular, when they are 
seated between the folds. They are best seen by looking 
obliquely at the surface of the gut. Together with the ulcers 
there are numerous pearl-like projections, surrounded by nar- 
row rings of congestion. These are enlarged solitary glands, 
and it is to their suppuration that the round ulcers are due. 
The whole mucous membrane is softened and thickened, un- 
less the disease has been of very long duration, when it becomes 
extremely thin. The mesenteric glands are swollen and may 
even be caseous. In exceptional cases, the lower portion of 
the ileum presents the same changes as the large intestine. 

Etiology. — Entero-colitis, or a series of attacks of simple 
diarrhoea, may establish chronic diarrhoea ; but the disease 
frequently arises insidiously from the constant action of the 
great exciting cause — improper food. This cause is most 
operative in hand-fed infants, and at the time of weaning, but 
it affects nurslings who are supplied with poor breast milk or 
allowed to eat bits of table food, and also older children. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 277 

Exposure to wet and cold is another excitant ; so, too, are 
various acute diseases, notably measles, croupous pneumonia, 
and typhoid and scarlet fevers. 

The predisposing agencies are bad hygienic surroundings, 
particularly overcrowding. With regard to age, the period of 
greatest liability, as well as greatest fatality, is from birth to 
the end of the second year ; afterward it grows less common 
as age advances. In our climate the greater number of cases 
originate in early spring and autumn, when the weather is 
most changeable ; and late winter, when it is cold and damp. 

Symptoms. — The first indication of the disease is an altera- 
tion in the character of the stools. These assume the color 
and consistence of putty, and, according to the composition 
of the food, consist of curd and farinaceous matter, with semi- 
solid faeces, and, at times, mucus and streaks of blood. They 
are voided with much pain and straining, but are little, if at 
all, increased in frequency. Their odor is offensive and sour. 
The face is pale and listless in expression, though the child is 
sufficiently lively, takes his food well, and has no fever. 

These symptoms continue with trifling change for two or 
more months, the patient gradually becoming thinner, paler, 
and more languid. Then for the first time diarrhoea, suffici- 
ently marked to arrest the nurse's attention, sets in. The 
evacuations now have a putrid odor, but vary considerably in 
other characters from day to day. They may be thin, liquid 
and brownish like dirty water ; or clay-colored, of the con- 
sistence of thin mud ; or watery, with particles of grass-green 
matter ; and, finally, they may be slimy and contain whitish 
masses of undigested curd or particles of other food. The 
number of movements varies from ten to thirty in twenty-four 
hours ; their frequency depending upon the amount of food 
taken and, to some degree, upon the weather, being greater 
on moist, cold days than on warm, dry ones. They are pre- 
ceded by pain, indicated by crying or uneasy movements of 



278 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

the legs, and are attended with straining, sometimes sufficient 
to cause prolapse of the rectum. 

The tongue is usually natural, though at times the tip and 
edges are too vividly red and the fungiform papillae too promi- 
nent. The appetite is normal, or even increased ; nevertheless 
wasting is continuous. The skin grows pale, dry, and harsh, 
and assumes a peculiar earthy tinge, which is deepest over the 
abdomen. The eyes are sunken and surrounded by dark 
circles ; the lips are bloodless and thin ; the nasal lines of 
Jadelot are marked, and the fontanelle is depressed. The 
abdomen may be soft and flaccid, but oftener is distended with 
flatus, and then is the seat of pain, manifested by moaning 
and twitching of the corners of the mouth. Palpation is pain- 
less unless there be ulceration ; in the latter case there is 
tenderness, and the contact of the hand causes borborygmus. 
The skin on the internal aspect of the thighs and the nates is 
reddened by intertrigo, due to the irritant action of the faeces 
and urine. Prostration is so great that the child lies perfectly 
passive ; the pulse is feeble and frequent ; the temperature is 
not elevated, but, on the contrary, the hands and feet often 
feel cold, and have a bluish color. 

The urine is diminished in quantity and retained for long 
periods. 

With occasional brief intervals of improvement the condi- 
tion gradually grows worse. The stools become more watery ; 
look like chopped spinach floating in brown, putrid water, and 
may contain mucus and pus with blood, in brownish-yellow 
masses. Abdominal distention, tenderness, and gurgling, the 
signs of intestinal ulceration, are present. The appetite is 
capricious or lost. The face becomes thin and pinched ; the 
forehead is wrinkled ; the hair dry and lustreless, and the 
whole expression that of a puny, weak, old man. General 
wasting progresses until the body seems to consist of little 
more than the bones, which stand out prominently, with the 



AFFECTIONS OF THE STOMACH AND INTESTINES. 279 

muddy, harsh, flaccid skin hanging from them in folds. To 
this emaciation the distended belly stands in marked contrast. 
The fontanelle, at this stage, is deeply depressed ; the pulse 
feeble ; the breathing superficial, and the temperature sub- 
normal, being sometimes as low as 97. 5 F. in the rectum. 

As the end approaches, the nasal lines increase in depth ; 
the lips are red, fissured, and encrusted with scales ; the 
tongue dry, red, and rasp-like from enlarged fungiform papillae, 
and the whole oral mucous membrane is covered with aphthae 
or thrush patches. A fetid odor hangs about the body. The 
feet and hands are cold, purple, and ©edematous. The little 
sufferer lies quiet, with half-shut, lustreless eyes ; from time 
to time an expression of pain flits over his face, but he is too 
weak to cry. Finally, there is no evidence of living, save the 
slow rise and fall of the chest as the breath comes and goes, 
and gradually this ceases, so gently that it is difficult to decide 
upon the exact moment at which life passes away. It is not 
uncommon for the discharges from the bowels to stop entirely 
for several days before the fatal termination. This circum- 
stance alone has no favorable significance. 

Death may result from exhaustion, or several complications 
may arise and hasten this event. These are serous effusions, 
hypostatic pneumonia, exanthemata, convulsions, and throm- 
bosis of the cerebral sinuses. 

Serous effusion may take place into the pleurae, peritoneum, 
and pericardium, but usually occurs in the form of oedema of 
the feet, hands, and, at times, the face. It is due to the im- 
poverished condition of the blood and want of tonicity in the 
vascular walls. 

Hypostatic pneumonia, due to the constant dorsal decubitus, 
is a common cause of death. 

The exanthemata are very prone to attack the subjects of 
chronic diarrhoea, probably on account of the attendant 
prostration reducing the power of resisting contagion. 



28o DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Convulsions are only dangerous in the early stages of the 
attack ; later, the nervous irritability is so blunted that this 
complication is rare. 

Thrombosis of the sinuses of the brain depends upon the 
withdrawal of the liquid elements from the blood by the diar- 
rhcea. Water is then absorbed from the brain, lessening its 
bulk. The resulting vacuum, together with atmospheric pres- 
sure from without, leads to depression of the fontanelle, and 
even overlapping of the cranial bones in young subjects. If 
this be insufficient to compensate, the cerebral sinuses and 
blood-vessels become engorged with blood, and as the natur- 
ally sluggish current in the sinuses is rendered more slow by 
concentration of the blood and feebleness of the heart, the con- 
ditions for clotting are most favorable. At the autopsy, the 
clot is usually found in the longitudinal sinus, completely 
obliterating the channel ; it is laminated, whitish, and adherent 
to the walls of the sinus, which are free from signs of inflam- 
mation. The veins that enter the sinus are distended with 
blood. The symptoms preceding death from this complica- 
tion are difficult respiration, stupor, dilatation of the pupils 
and strabismus, spasm of the posterior cervical muscles, ful- 
ness of the jugular veins, and unilateral facial paralysis. 

When the case tends to recovery, the evacuations become 
more solid and natural in odor and color ; the latter change 
being caused by the reappearance of bile. The semi-stupor 
disappears, and the child grows very irritable, often crying 
out and shedding tears — a most favorable omen. The flesh, 
also, begins to return, the buttocks being the first part of the 
body to show the improvement. Diarrhoea is, after a time, 
succeeded by a constipated condition of the bowels. Con- 
valescence is protracted. 

Children over two years of age, when affected with chronic 
diarrhoea, are pale, thin, languid, and readily fatigued. Irrita- 
bility of temper, night terrors, and nocturnal incontinence of 



AFFECTIONS OF THE STOMACH AND INTESTINES. 28 1 

urine are common. The tongue is red at the tip and edges, 
with prominent papillae, and perhaps light frosting. The 
appetite may be normal, craving, or capricious. The stools 
vary in number from three to twelve in twenty-four hours ; in 
the former case they are semi-solid, light-colored, and mixed 
with minute masses of green or colorless mucus ; in the latter, 
they consist of dark liquid, containing lumps of clay-colored 
faeces ; this variation bears some relation to the state of the 
weather. The evacuations are always fetid in odor, and the 
act of defecation is attended by pain and straining. The 
abdomen is distended by flatus. Feebleness of the pulse is 
proportionate to the general weakness ; respiration is unaltered, 
and there is no pyrexia. 

In some instances the stools are limited to four or five a 
day, and are composed almost completely of undigested food 
and mucus. One evacuation occurs in the morning, soon 
after rising ; the others during or immediately after meals. 
They are preceded by griping pain and by so urgent a desire 
that the patient has difficulty in waiting for the chamber or 
reaching the closet. The condition undoubtedly depends 
upon great irritability of the intestine and exaggerated 
peristalsis. 

Diagnosis. — The diarrhoea of chronic catarrh is to be dis- 
tinguished from that of tuberculosis of the intestines, the only 
condition with which it is likely to be confounded. Should it 
begin soon after birth or at weaning, if there be a history of 
bad feeding or exposure, and if there be no constant elevation 
of temperature, the affection is probably catarrhal. A tempo- 
rary rise in temperature may be caused by some passing irri- 
tation, and is of no diagnostic importance. 

Tuberculous diarrhoea, on the contrary, occurs after the 
third year, and is attended by pyrexia and enlargement of the 
mesenteric glands. On pressure there is tenderness and gurg- 
ling in the right iliac fossa, and tension of the abdominal wall 
24 



232 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

over this region. There is also evidence of tuberculosis of 
the lungs. The evacuations, too, are distinctive ; they are 
intensely fetid, brown and liquid, when passed, but, on stand- 
ing, deposit a dark sediment, composed of flocculent matter, 
with small, black clots of blood, and little masses of mucus, 
and pus. The presence, therefore, of these features or their 
absence, while the symptoms of catarrhal diarrhoea are ob- 
served, will determine the nature of the affection in children 
who have passed the age of infancy. 

Prognosis. — Chronic intestinal catarrh is fraught with great 
danger when it attacks children under the age of two years. 
It is particularly fatal when it follows an acute disease ; when 
it occurs in syphilitic, rachitic, or feeble subjects, and when it 
is complicated by measles or other exanthem. Unfavorable 
symptoms are dryness and roughness of the tongue ; thrush ; 
anasarca ; features indicating intestinal ulceration ; great de- 
pression of the fontanelle, and extreme emaciation. Favorable 
symptoms are normal progression of dentition ; the reappear- 
ance of tears ; intermissions in the diarrhoea, and improvement 
in the character of the stools and general symptoms. 

Treatment. — As the disease is produced by overcrowding, 
neglect, exposure, and unsuitable food, the initial measures of 
treatment must be the regulation of the hygiene, clothing, and 
diet. 

The sleeping-room must be kept at a uniform temperature 
— between 64 and 68° F. ; it must be dry, well ventilated, 
and, if possible, heated in cold weather by an open wood-fire, 
and occupied by no one but the patient and nurse. During 
the day the patient must be moved to another room, being 
wrapped in a blanket if cold halls have to be passed. This 
room should be large, well ventilated, dry, and kept at the 
same temperature as the first. After the removal, the windows 
of the sleeping-room should be opened, and the bed and its 
linen thoroughly aired and freshened. Soiled diapers or 



AFFECTIONS OF THE STOMACH AND INTESTINES. 283 

chambers containing stools are to be removed at once, and 
no cooking is to be done in either room. The child's person 
must be kept clean, and it is especially important to sponge 
the perineum and nates with warm water after each movement 
of the bowels ; and, if there be any redness of the skin, to 
anoint the parts with oxide of zinc ointment, or powder them. 
It may be impossible to carry out this plan among poor 
patients, but it can be approximated by keeping the baby 
clean, out of the kitchen, and away from the door-step. 

As to clothing, the body must be clad in woolen from the 
neck to the toes, and, as an additional protection, a broad 
flannel abdominal belt must be worn. So clothed, the patient 
may be taken into the open air on dry days, during the early 
stages of the attack. Soiled garments are to be replaced at 
once by fresh ones, and diapers must be washed when soiled, 
not simply dried and used over again. 

The diet should vary with the age of the patient ; the great 
principle being to maintain the general nutrition with the least 
amount of irritation of the intestinal mucous membrane. 

Infants partly nursed and partly bottle-fed do best when 
restricted to the breast, provided the latter be healthy. If the 
diarrhoea does not improve under the change, both the inter- 
vals and the time of nursing must be shortened. 

If the infant be hand-fed, every precaution must be taken 
to insure purity of food and perfect cleanliness of the feeding 
apparatus. The latter must consist of a simple bottle and 
tip, unless the amount to be given be very small, when a 
teaspoon can be used. The quantity of food and intervals of 
feeding always depend upon the degree of diarrhoea ; thus, 
in very severe cases, not more than a teaspoonful every 
fifteen minutes can be allowed. The quality depends upon 
the age. 

For an infant under six months, cows' milk and lime-water, 
in the proportion of one part to two or three, and sweetened 



284 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

with sugar of milk, may be tried. If this undergoes acid 
fermentation, fresh whey and veal- or chicken-broth, with 
equal quantities of barley water, may be substituted. At the 
age of six months, a good scale of diet when milk cannot be 
taken is : 

First meal, 7 a. m. — Veal-broth (y 2 lb. of veal to a pint 
of water) and barley water equal parts, 6-8 tablespoonfuls 
(fgiij-iv). 

Second meal, 10 a.m. — Cream, one tablespoonful (fgss); 
whey (freshly prepared), 12 tablespoonfuls (f§vj) ; sugar of 
milk, 1 teaspoonful (f5j). 

Third meal, 1 p. m. — Same as first, with chicken-broth in 
place of veal-broth. 

Fourth meal, 5 p. m. — Same as second. 

Fifth meal, 10 p. m. — Same as first. 

If feeble, one meal at 4 a. m., same as second. 

After a week or more of improvement, milk may be 
resumed gradually, in the beginning at the first meal only ; 
then at the first and last, and so on. Partial peptonization 
is an important intermediary in the resumption of milk feed- 
ing". 

o 

Should these foods disagree, they must be discontinued and 
the child fed upon raw-beef juice. This is prepared by 
chopping a piece of sirloin steak, free from fat or tendon, into 
small bits, and, after slightly warming, pressing out the 
juice with a lemon squeezer. One or two teaspoonfuls, with 
a little salt, is to be given every two hours ; and, at the same 
time, to keep the blood-vessels full, the patient must take 
from 12 to 24 fluidounces of pure water, barley water, or 
white-of-egg water each twenty-four hours ; these being given 
in small doses at short intervals. 

If there be much prostration, the yolk of a raw egg, well 
beaten with ten drops of brandy, a teaspoonful of cinnamon 
water, and a little white sugar, may be administered once or 



AFFECTIONS OF THE STOMACH AND INTESTINES. 28 



twice a day, together with the whey, broth, or raw-beef juice 
feeding. 

For a child over twelve months old, if milk can be taken, 
the following diet is suitable : 

First meal, 7 a. m. — Six ounces of milk and barley water, 
equal parts ; one teaspoonful of sugar of milk. 

Second meal, 10 A. M. — Four ounces of veal-broth with two 
ounces of barley water. 

Third meal, 2 p. m. — The yolk of a raw egg, beaten up well 
with twenty drops of brandy, a teaspoonful of cinnamon water 
and a little white sugar. 

Fourth meal, 6 p. m. — Same as second, or four ounces of 
fresh whey with a tablespoonful of cream, and one teaspoon- 
ful of sugar of milk. 

Fifth meal, 10 p. m. — Same as first. 

It is most important to remember that if the evacuations be 
very frequent and water}', there can be no set meals, but the 
food must be given by the teaspoonful at intervals of ten or 
fifteen minutes. Also, that between set meals and these 
minimum quantities, there is a wide range in the amounts and 
intervals, according to the grade of the symptoms. 

From older children it is necessary to withhold potatoes 
and farinaceous vegetables generally ; fruits, sugar, sweet- 
meats, pastry, hot bread or cakes, butter, and all made and 
highly seasoned dishes ; at the same time the bulk of each 
meal must be somewhat restricted. A good diet is : 

For breakfast, at 7.30 a. m. — One or two tumblerfuls of milk 
warmed, and diluted by the addition of a fourth part of hot 
water ; the yolk of a soft-boiled egg, salted, and a slice of 
thin, dry toast. 

For luncheon, at 12 m. — The soft parts of eight raw oysters, 
flavored with lemon juice, and a Boston cracker. Or in sum- 
mer a small teacupful of junket, with a cracker. 

For dinner, at 3 p. m. — A bit of the breast of chicken cut 



286 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

up very fine, or a tender piece of roast beef or beef-steak 
treated in the same way ; with a tablespoonful of well-boiled 
spinach, asparagus tops, cauliflower tops, or stewed celery, 
and a thin slice of dry, stale bread. 

For supper, at 7 p. m. — A glass of milk, warmed as at break- 
fast, and a slice of well-made cream toast. 

An important rule in all cases is to watch the diet carefully 
until all danger of a relapse has passed. 

Baths and external applications are useful. Infants who are 
not much prostrated should be placed in a hot bath (95°-ioo° 
F.) every evening for three minutes, then quickly dried, an- 
ointed over the whole body with warm olive oil, wrapped in 
a blanket, and put to bed. If there be much prostration, the 
bath must contain mustard, one teaspoonful to the gallon, and 
the child kept in until the supporting arms of the nurse begin 
to tingle. 

When intestinal ulceration is suspected, the belly should be 
enveloped in a light flaxseed poultice, or, what answers as 
well, a layer of carded cotton covered with oiled silk. 

Medicines are to be selected according to the stage of the 
attack. Early, while the stools are little increased in number, 
but putty-like and of sour odor, the bowels must be gently 
acted on by : 

R • Hydrarg. chloridi mit. , gr. ss 

Sodii bicarbonatis, gr. vj 

Pulv. rhei, gr. j. 

M. et ft. chart. No. vj. 
SiG. — One powder every hour until all are taken, for an infant of three to six 
months. 

Afterward — on the succeeding day, usually — the following 
may be administered : 

H- Bismuth, subcarb., . giss 

Essence of pepsin (Fairchild's), f^ij 

Elix. aromat. , f^j 

Aquae, q. s. ad f^iij. M. 

SiG. — Teaspoonful every two hours. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 287 

When the stools become frequent and green, the mixture 
of aromatic syrup of rhubarb, bismuth, and chalk, already 
given (page 275), is very useful, or : 

rj* . Beta-naphtol bismuth., gr. vj 

Bismuth, subcarb., gr. xxx 

Pulv. rhei, . gr. j. 

M. et ft. chart. No. xij. 

SlG. — One powder every two to four hours. 

If tenesmus be marked, the lower bowel should be washed 
out with a pint of normal saline solution at a temperature of 
98 ° F. once or twice daily. In very severe cases it is sometimes 
necessary to follow these flushings by a sedative enema, as : 

R . Tr. opii, gtt iij 

Potass, bicarb., gr. Iij 

Mucilag. amyli, . . fj§ss. M. 

SlG. — To be injected into rectum. 

This may be repeated every six or twelve hours, according 
to the necessity, taking care that the child — and all children 
are very susceptible — does not get too much opium. 

Should the diarrhoea still continue, and the stools become 
watery and very fetid, more powerful astringents are required ; 
for example : 

K . Acid, sulphurici aromat, n\xxiv 

Liquor, morphinae sulph., fspj 

Elix. curagoae, f 5 ss 

Aquae, q. s. ad f^iij. M. 

SlG. — One teaspoonful every three hours. 

Or— 

& . Argenti nitratis, gr. ss 

Syr. acaciae, f^ ss 

Aquae, q. s. ad f 3 iij. M. 

SlG. — One teaspoonful every three hours, midway between feedings, if 
possible. 

Nitrate of silver is most valuable when the stools contain 
mucus and blood, and aphthae or thrush are present. 



288 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

While administering remedies to arrest the diarrhoea, it is 
well to keep up the patient's general strength by tincture of 
nux vomica in doses of gtt. j-ij every six hours. Prostration 
and depression of the fontanelle demand stimulants. Ten 
drops of whiskey in water every two hours is about the 
average dose, but it may be given oftener and in larger quan- 
tities as circumstances require. 

As soon as the stools become normal in character and fre- 
quency, the child must be ordered tonics, as : 

ft . Tr. nucis vom., TlLxxiv 

Acid, nitro -rauriat. dil., TTLxij 

Elix. cinchon. cal., f^j 

Elix. aromat., q. s. adf^iij. M. 

SiG. — Teaspoonful three times daily. 



o 



ft . Ferri et ammonii citratis, gr. xij 

Tr. gentianse comp., fgj 

Spt. lavandulae comp., f^ij 

Syrupi limonis, q. s. ad f ^ iij. M. 

SiG. — One teaspoonful three times daily. 

For the constipation of convalescence very small doses of 
castor oil — twenty drops — may be ordered once or twice daily, 
but it is best not to interfere unless the bowels have been 
indolent for twenty-four or forty-eight hours. 

With older children the medicinal treatment is more simple. 
Ordinarily the following prescription will suffice : 

ft. Syr. rhei aromat., f^iv 

Bismuth, subcarb. , 3 i j 

Syr. acaciae, f # ^ ij 

Mist, cretae, q. s. ad f^vj. M. 

SiG. — Two teaspoonfuls every two hours. 

With this, tincture of nux vomica and essence of pepsin 
should be given three times daily after food. 

The lienteric form of diarrhoea should not be treated by 



AFFECTIONS OF THE STOMACH AND INTESTINES. 2(50. 

astringents, but by digestants, as pepsin and pancreatin, and 
by nux vomica followed by arsenic. For instance, until the 
stools become less frequent and urgent and the griping pain 
diminishes, a good prescription is : 

R. Tr. opii deodorat., 

Tr. nucis vomicae, aa tt^xlviij 

Aq. menthae pip., ........ q. s. ad f^iij. M. 

SlG. — One teaspoonful before each meal, at the age of six years. 

Afterward : 

& . Liq. potassii arsenitis, fgj 

Inf. gentianse comp., q. s. adf^iij. M. 

SlG. — One teaspoonful after each meal. 

Washing out the intestine is also a useful method of treat- 
ment. 

During convalescence from chronic diarrhoea, older children 
do well upon the same tonics as infants, the doses being pro- 
portionately increased. 



ENTERO-COLITIS. 

(Summer Diarrhoea — Febrile Diarrhoea?) 

Entero-colitis, or inflammatory diarrhoea, is the scourge of 
our large cities during the summer months, when it brings death 
to hundreds of children, especially among the overcrowded, 
ill-fed poor. To it is due the popular dread of that period of 
an infant's life termed "the second summer," and justly, for 
among those unfortunates who are obliged to pass this time 
in crowded houses, and narrow, filthy streets, the instances of 
complete escape are very rare. 

Morbid Anatomy. — The anatomical lesions consist in 
inflammatory hypersemia of the intestinal mucous membrane. 
This may be distributed over the whole tract, but commonly 



29O DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

it is limited to the ileum and colon, and is most intense in the 
neighborhood of the ileo-caecal valve and the sigmoid flexure. 
The mucous membrane is reddened, swollen, and softened. 
Redness is either general or in the form of arborescent patches 
about the follicles ; while swelling and softening are propor- 
tionate to the degree of congestion. The former is sometimes 
so great at the lower end of the ileum as almost to occlude 
the valve ; to this has been attributed the vomiting which, in 
the absence of gastric lesions, is otherwise difficult to explain. 
The isolated glands are enlarged, and more opaque than 
normal, having the appearance of grains of white sand scat- 
tered over the mucous surface, and the Peyer's patches are 
tumefied and projecting, with punctated surfaces. On the 
peritoneal aspect, the gut, in positions corresponding to the 
inflamed glands, presents areas of arborescent injection. There 
is moderate enlargement of the mesenteric glands. 

From this condition it is but a step to the state of ulceration 
seen in chronic intestinal catarrh — a not infrequent result oi 
entero-colitis. 

The stomach, as already hinted, is usually normal in appear- 
ance ; occasionally its mucous membrane is reddened and 
thickened, and it is quite possible that this viscus is often the 
seat of a catarrh so moderate in degree as to leave no evidences 
after death, though sufficient to give rise to vomiting during 
life. 

Etiology — Season, age, and locality of residence are 
important predisposing factors. Only isolated cases occur in 
the winter months, and these are met with among the poor, 
with whom it is a habit, for convenience in watching, to keep 
infants in the living room, which is also the kitchen ; this is 
heated by the cooking stove, and is either intensely hot when 
the room-door is closed, or too cold when it is left open, in 
the frequent excursions of the older members of the family to 
the yard or street. There is, therefore, a constant exposure to 



AFFECTIONS OF THE STOMACH AND INTESTINES. 20,1 

sudden and marked changes in temperature. At the same 
time the air of such a room is contaminated by cooking, by 
re-breathing, and by the exhalations from soiled clothing and 
dirty bodies. In other words, under these circumstances 
there is a combination of unsanitary influences tending to 
reduce the vitality and lessen the resisting power of the infant. 
About the middle of May or June, according to the char- 
acter of the individual season, cases become more common, 
and as the summer heats are established, in July, August, and 
the first half of September, the number is augmented to the 
proportions of an epidemic. Late in September or in October, 
according, again, to the season, there is a marked diminution, 
and this increases as winter approaches. During the summer 
the number of cases and deaths varies with the range of the 
thermometer ; several successive days with a temperature 
above 90 F. being attended by a great increase, while a 
similar period with a temperature below 8o° is followed by a 
decided decrease. Hot, damp weather is the most productive, 
and of all months August is the most fatal, both on this 
account and because a high temperature is maintained during 
the night. These atmospheric conditions predispose to entero- 
colitis by sapping nerve energy and opening the way for the 
action of the chief exciting cause : namely, unsound, bacteria- 
laden food. At the same time they encourage the very 
changes in the food which render it disease producing. 

Infants between the ages of six and eighteen months are by 
far the commonest sufferers. From the eighteenth month to 
the end of the second year, about one-fourth as many cases 
occur, and the third period of greatest frequency is from birth 
to the sixth month. Children over three years are not often 
attacked. Here, again, the questions of vital resistance, the 
manner of feeding, and the character of the food enter inti- 
mately into the causation. 

Residence in large cities and at a distance from the source 



292 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

of milk supply is an important etiological condition ; the vast 
majority of cases occur where the streets are narrow and 
more than ordinarily filthy, and where the houses are over- 
crowded and dirty, and the people poor, ill-fed, unclean, and 
careless as to the. condition of the cows' milk used in artificial 
feeding. There are other factors at work here besides the 
elevated temperature, since in the open country immediately 
surrounding affected cities, where the thermometer ranges 
nearly as high, the disease is of exceptional occurrence. 
These factors are an atmosphere polluted by poisonous gases 
and containing countless bacteria, the result of decomposing 
organic substances ; and the use of impure, bacteria-laden, 
artificial food. 

As already indicated, the most potent exciting cause is bad 
food. Infants hand-fed from birth are the most frequent 
sufferers ; next, those who are weaned early. In both, cows' 
milk, modified in some way, is the usual substitute for the 
maternal breast, and it is to injurious changes taking place in 
this fluid, through the influence of various forms of bacteria, 
that one must look for the origin of the majority of cases 
of entero-colitis. These changes are encouraged by high 
atmospheric temperature, and while they may occur in milk 
most carefully guarded at the dairy and in the nursery, are 
more rapid and intense if the handling be careless. Hence 
the prevalence of the disease during the summer months and 
among the city poor, who draw their supply from a distance, 
cannot afford the outlay for originally good, clean milk, or 
for ice to preserve it, and often lack the time to secure, or 
overlook the necessity of, clean receiving vessels and feeding 
apparatus. 

The disease may also be produced by the employment 
of farinaceous preparations in excess, and by " tastes " of 
table-food. Nursing infants are more exempt, but even with 
them too frequent and continuous feeding, or breast milk 



AFFECTIONS OF THE STOMACH AND INTESTINES. 293 

of abnormal quality, when the predisposing conditions are 
favorable, often produces entero-colitis. 

Symptoms. — For one or two days prior to the actual 
attack the infant is restless and fretful ; his sleep is disturbed 
by moaning or fits of crying ; he is paler than usual, and his 
head and, perhaps, the palms of his hands feel hot. He also 
ceases to empty his bottles ; after feeding, eructations of very 
sour-smelling material are apt to occur, and the stools are 
somewhat more numerous and softer than usual. 

Next, vomiting and diarrhoea set in. The former occurs 
after feeding, and, in bad cases, is so obstinate that nothing is 
retained. The matter rejected consists of sour, acid, and 
curdled milk, or other food imperfectly digested. 

The stools range from six to twenty or more in twenty- 
four hours, and vary in character from day to day, and even 
from hour to hour. At first, they are semi-solid, homo- 
geneous, yellow in color and neutral in reaction ; then they 
become more liquid and green, though still homogeneous and 
neutral, and then the reaction becomes acid without change 
in the other characters. Often they are semi-fluid, hetero- 
geneous, green with little masses of yellow faeces, and neutral ; 
or semi-fluid, heterogeneous and green, with fragments ol 
yellowish-white casein, and acid ; or watery, with floating 
flakes of white, yellow, or green matter, and acid. Mucus 
and blood may be mixed with any of these stools ; the 
first in stringy masses ; the second, in bright red streaks or 
merely tingeing the mucus. In severe cases the passages 
become watery and so colorless as hardly to stain the diapers. 
The odor at first is faecal, then sour, and finally offensive. 
The act of defecation is preceded by pain, manifested by the 
expression of the face, by crying, and by twisting of the trunk 
and drawing up of the legs. Sometimes there is tenesmus 
and slight prolapse of the rectum ; it is under these circum- 
stances that blood appears in the stools. 



294 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

The tongue is dry, red at the tip and edges, and covered in 
the centre with a light white coating ; thirst is increased. The 
abdomen is distended by flatus, and, at times, there is tender- 
ness on pressure. 

With these features there is pyrexia, rarely exceeding 103 
F., and continuous for the first three or four days, afterward 
remittent ; the head is especially hot, and the palms of the 
hands are dry and burning to the touch. The pulse is weak 
and frequent, beating 1 20, or even 140, times per minute. The 
urine is reduced in quantity and passed at long intervals ; 
sometimes only two or three times a day. 

As the diarrhoea continues the face becomes pale ; the eyes 
are surrounded by dark circles ; the nasal lines appear ; the 
fontanelle, if still membranous, is depressed ; the fat disap- 
pears from the body ; the muscles grow soft and flabby ; the 
buttocks and inner surfaces of the thighs are reddened by the 
acid stools and concentrated urine, and there is great feebleness 
and languor. In grave attacks these changes take place in an 
incredibly short space of time, twenty-four hours being ample 
to reduce an active, robust infant to a mere shadow of himself. 

If death approach, the patient, in some cases, grows fretful ; 
has a dry, burning skin ; rolls the head from side to side ; 
vomits incessantly ; has strabismus and indolent pupils, and 
may have convulsions, which are more frequently unilateral 
than general. In others, there is drowsiness, an apathetic re- 
fusal of food, cessation of vomiting and diarrhoea, and coolness 
of the extremities. This difference depends upon the acute- 
ness of the attack, for upon this rests the preservation or loss 
of nervous irritability. 

The great diminution of the urinary excretion suggests the 
possibility of the fatal termination being, in some instances, 
due to uraemic poisoning. 

When the attack tends to recovery, the vomiting stops ; the 
motions are less numerous and more faecal ; the temperature 



AFFECTIONS OF THE STOMACH AND INTESTINES. 295 

falls ; the pulse becomes slower and the skin cooler and more 
moist ; the urine is excreted freely ; the eyes grow bright ; 
the child again shows interest in his surroundings ; takes his 
food better, and rapidly regains flesh and strength. 

Diagnosis. — The pyrexia, the vomiting, and the frequency 
and character of the stools, taken in conjunction with the 
early age of the patient ; the season and locality of occur- 
rence ; and the almost epidemic prevalence of the disease, 
make its distinction an easy matter. The portion of the 
intestinal canal chiefly involved is not so readily determined, 
though the presence of mucus and blood in the evacuations 
points to the colon as the seat of inflammation ; their absence, 
by inference, to the small intestine. It is important to differ- 
entiate this disease from cholera infantum or "acute milk in- 
fection," which is an infinitely more serious disease. Cholera 
infantum is sudden in its onset, characterized by a high tem- 
perature, from 105 F. to 108 F.; uncontrollable vomiting; 
frequent and profuse serous evacuations ; embarrassed respi- 
ration ; frequent and irregular pulse ; marked involvement of 
the nervous system, and rapid collapse. Often a case will 
pass in the course of twenty-four hours from blooming health 
into a condition of almost ante-mortem decomposition. We 
do not see these changes in entero-colitis. 

Prognosis. — Inflammatory diarrhoea ranks among the most 
dangerous of the affections of infancy, both from its inherent 
nature and its tendency to run into chronic entero-colitis. 
Nevertheless, under appropriate management, a large propor- 
tion of cases recover. The outlook is most discouraging 
when the infant's lot has been cast in poverty ; when it has 
been hand-fed from or soon after birth ; and when it has had 
the bad fortune to be born in the late winter or spring, so that 
weaning and the necessity for artificial feeding come in the 
summer — " second summer." 

The unfavorable features are high fever, very frequent and 



296 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

watery evacuations, rapid collapse, cerebral symptoms, and 
convulsions. 

An attack may prove fatal in four or five days, or it may be 
protracted for two weeks. The latter is about the duration of 
severe cases that terminate in recovery. One attack predis- 
poses to another, an important point to remember in the treat- 
ment by change of climate. 

Treatment. — People with means avoid the dangers of 
summer diarrhoea by taking their children to the country, 
sea-shore, or mountains, where the air is uncontaminated, the 
heat less intense, and the milk pure. Such escape is not open 
to the children of the poor ; nevertheless, much may be done 
to preserve their health by keeping them during the day in 
the fresh air of public parks ; by bathing in cool water ; by 
proper, cleanly clothing ; by Pasteurization and careful hand- 
ling of milk and cleanliness of feeding apparatus, and by 
attention to the cleanliness of beds and sleeping rooms. This 
the parents can, and in many cases will do ; and if, with these 
precautions, they would insist upon decently clean streets, 
entero-colitis would become a far less common disease. 

When an attack occurs during the hot months, the patient, 
if possible, must be sent at once from the city to the sea-side 
or country. The locality selected should be near at hand, or 
the journey will be too fatiguing; still, it is important to fix 
upon a place affording a decided change of air and a lower 
temperature. From Philadelphia the infant may be taken to 
Atlantic City, Cape May, Point Pleasant, Avon, or any of the 
many resorts on the Jersey coast, kept there for two or three 
weeks and then removed to the New Hampshire hills for the 
remainder of the summer. A long stay is essential, since a 
return to town in hot weather is almost certain to be followed 
by a relapse. , , 

If circumstances render it impossible to carry out this most 
potent of all prescriptions, fresh air must be secured by taking 



AFFECTIONS OF THE STOMACH AND INTESTINES. 297 

the child to the public squares in the cool of the morning and 
evening, or by spending the day in the Park, or, better still, 
by a morning and evening trip on one of the river steamboats. 
The heat of the day must be spent in as cool a room as can 
be had. It is of great moment to let the little sufferer rest in 
bed and not on the hot lap or shoulder, and when out, to wheel 
him in a coach rather than carry him. Many. a stout mother has 
hastened her infant's death by too fond and constant nursing. 

The clothing must be as thin as possible, provided, always, 
that woolen be worn next the skin. 

Twice or three times a day, in very hot weather, the whole 
surface of the body should be sponged with water at a tem- 
perature of 8o° F., and dried with gentle rubbing. The brac- 
ing effect of these baths is greatly increased by the addition 
of rock salt, or concentrated sea- water if the purse can afford 
it. These cool spongings must be supplanted by full warm 
baths when there is much prostration. 

In regulating the diet, it must be remembered that the pres- 
ence of fever, with increased thirst, leads the child to take 
more liquid food than is needed or can be digested ; conse- 
quently, it is necessary to specify the quantity as well as the 
quality of the food. Infants at the breast are to be suckled 
only at intervals of two or three hours, according to their age, 
and taken away before they have completely satisfied them- 
selves. 

Hand-fed babies are to be similarly restricted. As cows' 
milk must constitute the bulk of their food, it is important to 
see that it is obtained fresh every day from a reliable dealer, 
promptly Pasteurized, and administered from an absolutely 
clean bottle fitted with a simple tip. For example : 

Milk, f 3 iij 

Cream, f^ss 

Lime water, . f^iiss 

Sugar of milk, . . . ^j. . *" 

25 



290 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Mix in a clean tin-cup, pour into bottle, adjust tip, and 
warm by plunging into hot water. 

This food may be given every three hours to a child ten 
or twelve months old. The quantity is less and the dilution 
greater than for a healthy infant of the same age, because 
enfeebled digestion demands a proportionate reduction in the 
amount and strength of the food. 

When preparations of milk are vomited or passed undigested 
from the bowels, a whey mixture can be resorted to : 

Whey, 4 tablespoonfuls (f^ij) 

Barley water, . 4 tablespoonfuls (f ^ ij) 

Milk sugar, I teaspoonful (gj). 

For one portion, to be given every two hours. 

Cool filtered water should be allowed, in moderation, and 
at short intervals, to relieve the thirst. 

If vomiting be persistent, all food must be stopped for from 
twelve to twenty-four hours, and the thirst quenched by 
barley water or Vichy water, — cool, and in small quantities. 
If the child be at the breast, as soon as vomiting is checked it 
can gradually be brought back to its accustomed diet, care 
being taken that too much food be not given. 

In bottle-fed children under two years, when the attack is 
at all severe, it saves time, and often life, to begin the treat- 
ment by withholding milk entirely ; whey, chicken- and mut- 
ton-broth, Mellin's food with barley gruel, and the juice 
expressed from raw beefsteak or roast beef should constitute 
the " no-milk diet." For instance : 

Barley jelly, I teaspoonful 

Water, 8 tablespoonfuls (f^iv). 

Mix and add half the white of a fresh egg. 
For one portion, to be given every two hours. 

Or: 

Veal-broth (% lb. of meat to a pint of water), 

Barley water, of each, 4 tablespoonfuls. (f^ ij). 

JFor one portion, to be given every two hours. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 299 

Or: 

Raw-beef juice, 1-2 teaspoonfuls (f^j-ij). 

Every two hours. 

While on raw-beef juice the patient must take from 12 to 
24 fluidounces of pure water, barley water, or white-of-egg 
water each twenty-four hours ; these must be given in small 
doses at short intervals. 

Resume milk-feeding gradually after using any of these 
preparations. Partially peptonized milk food is the best inter- 
mediate diet. Make each bottle of food as follows : 

Cream, I tablespoon ful (f J ss) 

Milk, 5 tablespoonfuls (f^iiss) 

Water, 4 tablespoonfuls (f^ij) 

Peptogenic milk powder, I level teaspoonful. 

After mixing, heat cautiously over a flame for six minutes, stirring constantly 
with a spoon, and tasting often, so that it shall not become too hot to be 
sipped — 1 1 5 F. Cool to 98 F. before administering. 
Feed every two and a half hours from 5 A.M. to 10 P.M. 

In case each bottle cannot be prepared separately, — by far 
the better way, — the whole quantity for each day may be pre- 
pared in the morning as follows : 

Cream, 8 tablespoonfuls (f :§ iv) 

Milk, 40 tablespoonfuls (f^xx) 

Water, 32 tablespoonfuls (f^xvj) 

Peptogenic milk powder, 8 level teaspoonfuls. 

Heat slowly, so as to bring to a full boil at the end of ten minutes ; fill eight 
graduated nursing bottles to the five-oz. mark, cork with cotton, and place 
in nursery refrigerator ; heat to 98 F. at time of administration. A mix- 
ture stronger than 2 parts of milk to I part of water is difficult to predigest 
without curdling, especially if the milk be of more than ordinarily good 
quality. 

To return to unpeptonized diet, gradually reduce the time 
of heating, and finally replace the milk powder by sugar ot 
milk and salt. 

The indications for medical treatment may be grouped under 
four heads : (i) To clear out the bowels ; (2) to stop decom- 



300 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

position ; (3) to restore healthy action in the alimentary tract ; 
(4) to treat the consecutive lesions. 

1. The bowels should be emptied as completely as possible, 
as the first step in the treatment, and for precisely the same 
reasons that the surgeon cleanses a wound thoroughly before 
applying antiseptic dressing. This rule holds good not only 
where there is a history of antecedent constipation, or the 
evidence of the presence of indigestible food in the alimentary 
tract, but in every case in which there are altered secretions 
undergoing putrefactive changes. The only instances in which 
the process of cleansing should not be undertaken, because 
unnecessary, are those where, after two or three faecal or semi- 
faecal evacuations, the discharges consist of almost pure serum, 
large in amount, alkaline in reaction, and odorless. 

To sweep out the intestinal canal nothing compares in effi- 
cacy with castor oil. Should the stomach be very irritable, 
however, it will be necessary to substitute enemata. These 
should consist of normal saline solution at a temperature of 
98° F., and to be efficient must be copious enough to reach 
the caecal valve — about one pint in a child of six months, and 
two pints in one of two years. The injection must be given 
slowly, with a fountain syringe, the abdomen meanwhile being 
gently manipulated. 

Many mild cases can be cured, if taken at the start, by cas- 
tor oil and a strict diet alone. 

2 and 3. To stop decomposition and restore a healthy action 
in the intestines, the administration of antiseptics is necessary. 

Antiseptics must be given in small doses lest the stomach 
reject them, and frequently, to maintain a continuous action. 
The best are betanaphtol bismuth, calomel, and salicylate of 
sodium. 

Betanaphtol bismuth is a true and most reliable intestinal 
disinfectant. It is non-irritating to the stomach and may be 
administered in powder, either alone or combined with sub- 



AFFECTIONS OF THE STOMACH AND INTESTINES. 3OI 

carbonate of bismuth in doses of gr. ss to iij, according to the 
age of the patient, repeated every two hours. It acts rapidly, 
and, on this account, must be carefully watched and the inter- 
val between the doses increased lest constipation, with locking 
of irritant intestinal contents, be produced. 

Calomel may be prescribed in the following combination : 

R. Hydrargyri chloridi mit., gr. ss 

Bismuthi subcarbonatis, ......... gr. xxxvj 

Pulv. aromatici, * gr. vj. 

M. et ft. chart. No. xij. 
SlG. — One powder every two hours. 

Salicylate of sodium is prescribed in doses of from one to 
three grains every two hours, according to the age, from three 
months to three years. An aqueous solution is tasteless, and 
can readily be given in the food or drink ; it has a tendency 
to check rather than occasion vomiting. It may also be sub- 
stituted for the calomel in the above prescription. 

Naphthalin is also recommended ; although possessing a 
strong odor, it is not disagreeable to the taste. On account 
of its insolubility, it is best administered rubbed up with sugar 
of milk. The doses should be larger than those of the sali- 
cylate of sodium — one to five grains, according to the age. 

Resorcin and bichloride of mercury are also useful antisep- 
tics. Resorcin is bitter, and though freely soluble in water, 
not easily administered ; the dose is one-half a grain to two 
grains. The bichloride is given in doses of y^ to T ^ of a 
grain, but even in these minute quantities frequently causes 
vomiting. 

Counterirritation by mustard plasters to the belly is useful. 
Stimulants are required when prostration sets in, and must be 
given in doses and at intervals adapted to the demands of the 
case ; and it is well from the beginning of the attack to main- 
tain the vital forces with appropriate doses of tincture of nux 
vomica or strychnine. 



302 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Applications of oxide of zinc ointment, with cleanliness, 
cure the intertrigo of the buttocks and thighs most quickly, or, 
at least, keep it in check until the cause is removed. 

4. The essential consecutive lesions are in the colon, and 
consist practically of a follicular colitis.- When the condition 
of ulceration is reached, astringents by the mouth are useless, 
with the possible exception of bismuth. 

Three things are valuable : 

First. As careful attention to the diet as during the acute 
stages, and in recent cases. Deviation from dietetic rules is 
the most frequent cause of relapse. 

Second, The continuance of antiseptics to check intestinal 
decomposition, and hence stop irritation. 

Third. The whole large intestine should be washed out once 
every day, either with normal saline solution at 98 ° F., or 
with weak antiseptic or astringent solutions. Of the former, 
the best are benzoate or salicylate of sodium ; of the latter, 
nitrate of silver or tannic acid. 

Attention to diet and hygiene are not to be relaxed when 
convalescence is established, and after the measures calculated 
to check diarrhoea are unnecessary, digestants, as wine of 
pepsin, and tonics, as the ferrated elixir of cinchona, are still 
required, to restore health. 

The exceptional cases that occur in cold weather should, of 
course, be treated at home in a well-ventilated and warm 
room ; otherwise, the only alteration to be made in the general 
plan of management is to envelop the abdomen with light lin- 
seed poultices, or with cotton covered by oiled silk. 



CHOLERA INFANTUM— ACUTE MILK 
INFECTION. 

This affection is encountered in children artificially fed upon 
cows' milk variously modified, and occurs during the hot 



AFFECTIONS OF THE STOMACH AND INTESTINES. 303 

months of summer, when toxicogenic germs are most widely 
distributed, and is characterized by a sudden onset, high fever, 
irritability of the stomach, frequent serous evacuations, changes 
in the respiration and pulse, marked symptoms of nerve in- 
volvement, and rapid collapse. It is a far less common disease 
than enterocolitis, and it is probable that the germs which 
produce it are less abundant than those causing the latter dis- 
ease and that the poisons generated in this form are more 
virulent. 

Morbid Anatomy. — In cases that run the ordinary course 
and die early, the gastro-intestinal mucous membrane is con- 
gested, thickened and softened, and the follicles and Peyer's 
patches are enlarged. In other words, the appearances indi- 
cate the early stage of inflammation, which passes into lesions 
identical with those of entero-colitis, when the patient, as 
sometimes happens, survives the choleraic stage and dies, sub- 
sequently, from a more protracted diarrhoea. But, in addition 
to inflammation, there is probably — and this is the important 
point — some involvement of the sympathetic nerves, leading 
to dilatation of the capillaries and transudation of serum into 
the intestine, and to alterations in the pulse, temperature, res- 
piration, and urinary excretion. The nature of this is paral- 
ytic, so far as the intestine is concerned, and resembles in its 
results experimental section of the sympathetic nerves. It is 
due, chiefly, to the direct irritant influence of the poison-laden 
contents of the canal, and in part, perhaps, to the nerve ex- 
haustion produced by high atmospheric temperature, one of 
the essential conditions for the development of cholera in- 
fantum. The changes in calorification and in the functions of 
the heart, lungs, and kidneys are most probably toxic. 

Etiology. — Like entero-colitis, this is a disease of cities, 
finding its victims chiefly among those who live in poverty and 
squalor. Almost exclusively confined to hot weather, it may 
occur at any time between the middle of May and the end of 



304 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

September, though the greater proportion of cases originate 
during the latter half of July, August, and the first half of 
September. Infants from six to twelve months are most sus- 
ceptible, though it may occur at any age up to two years. It 
is practically confined to subjects artificially fed upon some 
modification of cows' milk, and while the particular toxicoge- 
nic germ or its resultant poison present in the food has not 
been isolated, there can be no doubt that the causal factor is 
a bacteria-produced toxic element existing in the milk when 
administered, or formed in it, after entering the intestinal 
canal, by the growth of bacteria. High temperature (85 °- 
95 F. or more) sustained for several days, and especially if 
associated with a moist atmosphere, predisposes to attack by 
exhausting the infant's vital resistance ; such conditions also 
encourage bacterial changes in impure, carelessly handled 
milk, and therefore augment the prevalence and increase the 
activity of the exciting cause. 

Symptoms. — An attack usually arises in the midst of 
health, the onset being sudden. The infant begins to void 
copious stools. These at first, if there be no premonitory 
diarrhoea, contain more or less faecal matter, but they soon 
become watery. Sometimes they are so serous as to soak 
away into the diaper without leaving any stain ; at others, 
they contain a few yellow or green flocculi or little masses of 
mucus, and, in both instances, are odorless. Again, they are 
composed of yellow or brown liquid, containing a small pro- 
portion of thin, faecal matter, and have a peculiar musty and 
offensive odor, which clings to the napkins and clothing, and 
even to the body of the child, in spite of the utmost efforts at 
cleanliness. The number varies from eight to thirty in twenty- 
four hours, and they are evacuated with considerable force. 

At the same time, or soon after, the stomach becomes so 
irritable that everything, even to a mouthful of water, is re- 
jected as soon as swallowed, and there is violent retching with 



AFFECTIONS OF THE STOMACH AND INTESTINES. 305 

the expulsion of bile-stained mucus. Appetite is lost, but 
there is intense thirst, the patient eagerly drinking when the 
opportunity offers, and following the glass, as it is removed, 
with greedy eyes. The tongue, originally moist and lightly 
frosted, soon becomes dry and pasty, and protrudes from the 
parched lips. The abdomen is flaccid and indolent. 

There is great restlessness ; the temperature is elevated to 
105 ° or even 108 F.; the pulse is small and very frequent, 
counting from 130 to 150 beats per minute; the breathing 
becomes irregular and anxious, and the urine is greatly dimin- 
ished in quantity. 

With these symptoms there is a marked and appalling 
change in appearance. Within a few hours, the infant, per- 
haps plump and rosy before, can scarcely be recognized ; the 
face becomes pale and pinched ; the eyes and cheeks sunken, 
and the eyelids and lips permanently parted from loss of 
muscular contractility ; the fat melts from the body ; the 
muscles grow flabby ; the bones appear prominent, and the 
skin, often greenish or cadaverous in hue, hangs in folds. 

Soon the features of collapse appear. The hands, feet, nose, 
and even the breath, become cool ; the pulse is thready and so 
frequent as to be uncountable ; the respiratory movements are 
more unequal, and there is drowsiness, apathy, and suppres- 
sion of urine. As life ebbs away, the vomiting stops ; the 
surface becomes cold and clammy, though even in this stage 
the rectal temperature may remain high, the thermometer 
ranging about 107 or 108 F.; the face is set with lines of 
death ; the respiration is quickened and shallow ; the pulse 
scarcely perceptible, and the patient sinks into a state of semi- 
coma, with bleared eyes and contracted pupils. In this con- 
dition the end may come quietly or be preceded by slight 
convulsions. 

The course of the disease, whatever the result, is always 
very short. It may prove fatal in from one to three days, or 
26 



306 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

the character of the attack may change and death result later 
from a secondary inflammatory diarrhoea. 

In case of recovery, the stools, after three or four days, 
gradually become less copious, frequent and watery, more 
faecal and of better odor ; vomiting stops ; thirst diminishes ; 
appetite returns ; the urinary excretion is reestablished ; the 
temperature and pulse fall ; the respiratory movements be- 
come rhythmical ; emaciation ceases, and the child, though 
very feeble, again notices his surroundings, and after a week 
or more of simple diarrhoea, regains a moderate degree of 
health. 

Diagnosis. — The character of the stools, the extreme irri- 
tability of the stomach ; disturbed respiratory rhythm ; high 
temperature ; increased thirst and rapid emaciation and col- 
lapse, distinguish this from entero-colitis, and from other forms 
of diarrhoea. 

Asiatic cholera alone presents similar symptoms, and in case 
of the prevalence of this disease, bacteriological investigation 
of the evacuations from the bowel would be necessary to 
establish a diagnosis. 

Prognosis. — The prospect is most discouraging, the usual 
outcome being death ; even in seemingly favorable instances 
the opinion as to the result must be guarded, for though the 
choleriform symptoms be survived, there is danger from the 
succeeding diarrhoea. The disease is most fatal in children of 
the poor, who are badly fed and subjected to the worst hygienic 
influences ; conversely, it is more apt to terminate in recovery 
in the rich, who can be treated in large, airy rooms, have 
proper feeding and nursing, and be removed to healthy 
localities. 

Treatment. — Cholera infantum, being the result of the 
ingestion of an irritant poison, must be treated energetically 
and upon certain well-defined lines. The indications are : 

First, to remove the toxic elements from the gastro-intes- 



AFFECTIONS OF THE STOMACH AND INTESTINES. 307 

tinal canal and guard against their reintroduction by abso- 
lutely withholding milk or milk preparations. 

Second, to counteract the depressant action of the poison 
upon the centres of circulation and respiration, and upon the 
nervous system generally. 

Third, to supply to the blood the fluid drained away by the 
excessive purgation. 

Fourth, to reduce temperature and meet special symptoms 
as they arise. 

First. The most rapid and efficient methods of fulfilling this 
indication are stomach-washing, flushing of the colon, and the 
administration of a purgative dose — gr. ij to v — of calomel. A 
normal saline solution at ioo° F. for cleansing the stomach, 
and 8o° F. for irrigating the colon, should be employed ; both 
procedures should be thorough and repeated in six hours if 
the vomiting and purging persist or return after being relieved ; 
while apparently radical measures, they produce a degree of 
exhaustion quite insignificant when compared with that which 
rapidly follows the repeated vomiting and purging incident to 
the disease. 

The calomel purge should not be administered until after 
the stomach has been washed ; its main purpose is to clear out 
the small intestine, which can not be reached by irrigation, 
but it has, in addition, a beneficial antiseptic action. After the 
colon has been thoroughly cleansed, Vaughan recommends 
an injection of cool water containing gr. xv-xxx of tannic acid 
to the pint, for the purpose of neutralizing the remaining poi- 
sonous proteids. 

To prevent the reintroduction of the poison, milk in every 
form should be strictly prohibited, and the patient, for the 
first twenty-four hours, be allowed only pure, cool water in 
small quantities at short intervals, or, at most, cool water with 
raw -beef juice or panopepton, in one-half to one teaspoonful 
doses every two houcs. 



308 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Second. The effect of the poison upon the vital forces must 
be combated by stimulants. These include good brandy or 
whiskey given hypodermatically, or by the mouth in full 
doses, sufficiently diluted with water ; together with strych- 
nine, and morphine with atropine administered hypoder- 
matically. At the age of twelve months sulphate of strych- 
nine may be given at first in doses of gr. yi^ every four to six 
hours and increased as the intensity of prostration demands ; 
gr. t ^-q of sulphate of morphine with gr. -^^ of sulphate of 
atropine is the proper initial dose, and the injection may be 
repeated every two to four hours, the guide being the effect 
upon the vomiting and purging, the pulse and nervous symp- 
toms generally, all of which these drugs tend to improve. 
Care must be taken not to produce narcosis, and drowsiness 
and coma are absolute contraindications. 

Third. Fluids administered in any bulk by the mouth are 
expelled almost as soon as swallowed, and enemas are but 
little better retained, therefore the only successful way of 
replacing the liquid wasted by the excessive purgation is by 
hypodermoclysis. For this purpose a sterile normal saline 
solution should be employed and thrown into the subcutan- 
eous cellular tissue of the abdomen, buttocks, or back ; the 
quantity administered, in divided doses, should be at least 
eight fluidounces in each twelve hours ; this solution is rapidly 
absorbed and causes no irritation. 

Fourth. Antipyrin, phenacetin, or other antipyretic drug 
should never be used to reduce temperature in cholera infan- 
tum. When the fever is moderate, — 102°, — an ice cap or 
cold-water bag to the head may be all that is necessary ; when 
it mounts to 103 ° or 104 , cold water should be applied, with 
friction, to the surface every two hours or oftener if required 
to keep the temperature within bounds. If the pyrexia 
reaches 105 ° or more the patient must be immersed in a full 
bath, warm at first, and gradually cooled to 8o° by the addi- 



AFFECTIONS OF THE STOMACH AND INTESTINES. 309 

tion of ice ; the surface must be well rubbed during the bath, 
which may be prolonged for ten minutes after the water has 
been cooled, and repeated as demanded. Cold-water enemas 
are useful adjutors of the baths in severe cases. 

Collapse with cold extremities calls for hot mustard baths 
or packs, the constant application of dry heat by hot-water 
bags, and the subcutaneous injection of whiskey and strych- 
nine. The clothing, diapers, and person must be kept perfectly 
clean; the sick-room must be as large and airy as can be 
commanded, and the infant must lie upon a bed, and not be 
constantly nursed upon the lap. 

In the fortunate instances in which this plan is successful, 
and after the vomiting has been thoroughly controlled, the 
" no milk " diet suggested for entero-colitis may be attempted, 
but convalescence must be completely established before ven- 
turing upon any food containing milk. It is also necessary 
to treat the succeeding diarrhoea by the same measures as 
employed in entero-colitis ; and, finally, to build up the gen- 
eral health by good food, tonics, and fresh air. If it be pos- 
sible, the patient should be sent early to the sea-shore or 
country, as this affords by far the best chance for recovery. 
Failing in this, morning and evening airings in a coach, or 
daily steamboat excursions, must be resorted to. 



INFLAMMATION OF THE COLON AND RECTUM 
— ILEO-COLITIS— DYSENTERY. 

Dysentery is not a common disease of infancy or childhood, 
but it may occur in one of three forms : the catarrhal, the 
amoebic, and the membranous. 

CATARRHAL DYSENTERY. 
This form may arise at any period of childhood, but is most 
frequent after the first and up to the tenth year. It may be 



3IO DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

sporadic, endemic, or epidemic, and is confined to no class, 
locality, or season, though it is most often encountered 
among the poor, in crowded unsanitary quarters of large cities, 
and during the hot months of summer and early autumn. 

Etiology. — Subjects enfeebled by such diseases as tuber- 
culosis, constitutional syphilis, and rickets are prone to be 
attacked ; so also those depressed by exposure and want. 
However, the predisposing and exciting causes are similar to 
those of entero-colitis — impure food, in other words — bacteria 
playing an important role, though a specific germ has not as 
yet been discovered. 

Morbid Anatomy. — The lesions are situated, as a rule, in 
the rectum and lower portion of the colon, but they may 
involve the whole length of the large intestine and extend into 
the ileum. They consist of circumscribed or general hyper- 
emia of the mucous membrane, which is covered with tena- 
cious mucus, swollen, grayish, dark red, or purple in color, 
and sometimes the seat of punctiform hemorrhages. The 
solitary lymph follicles are enlarged and surrounded by areas 
of congestion. Ulceration may occur ; in the beginning, the 
ulcers are superficial and round, but they soon deepen and by 
coalescing become irregular in outline and large — measuring 
half an inch or more in diameter ; their edges are everted and 
flattened. The necrosis often extends to the muscular coat 
and in rare cases involves the entire intestinal wall, leading to 
perforative peritonitis. The mesenteric glands are enlarged, 
congested, and softened, and the liver is usually hyperaemic, 
and sometimes suppuration takes place in this viscus, with the 
production of multiple abscesses. 

Symptoms. — The attack may be preceded by a more or 
less prolonged diarrhoea, or begin suddenly with, in some 
cases, rigors or more distinct chills. There is moderate fever, 
the temperature ranging from two to four degrees above nor- 
mal ; the pulse is increased in frequency, and has a tendency 



AFFECTIONS OF THE STOMACH AND INTESTINES. 3 I I 

to rapidly become small and compressible. The tongue is 
moist and covered with a light, white fur ; there is nausea, 
sometimes vomiting, and a constant desire to evacuate the 
bowels, with pain and straining during and after the act. The 
stools are small in quantity and numerous, ranging from four 
to forty a day. At first they contain faecal matter, but after a 
short time are composed entirely of mucus and blood, mixed 
with yellow or green flocculi and pus. The blood may appear 
in dark red streaks or clots, in black masses, as a substance 
resembling the washings of meat, or merely diffused through 
the mucus, giving it a uniform red color. The evacuations at 
first are offensive ; later they become odorless or have a 
" fresh-meat odor." The urine is high-colored and diminished 
in quantity ; sometimes there is suppression with vesical ten- 
esmus. 

The face wears an anxious expression ; there is great rest- 
lessness, sleeplessness, muscular weakness, and rapid emacia- 
tion. The tongue becomes dry, red at the tip and edges, and 
covered in the centre with a brownish coating. There is anor- 
exia, urgent thirst, and vomiting. The abdomen is distended, 
tympanitic, and painful on pressure, particularly over the 
course of the colon. 

As the attack progresses, tenesmus becomes the most prom- 
inent symptom ; it occurs without the passage of stools, and 
is often attended with prolapse of the rectum. Fever gives 
place to coolness of the surface ; restlessness, to semi-stupor ; 
the eyes and cheeks sink ; the face becomes pinched, and death 
may take place quietly or be preceded by convulsions. 

The duration varies from two or three days in grave cases, 
to about two weeks in those that result favorably. 

The diagnostic features are fever, tenderness along the 
track of the large intestine, tenesmus, and the number and 
character of the stools. 

The prognosis is favorable in the sporadic form and when 



312 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

there is only slight elevation of temperature and moderately 
frequent stools. Quite the reverse, if there be high fever, 
great tenesmus, frequent evacuations containing much blood 
and pus ; when there is a tendency to collapse ; when there is 
marked restlessness, stupor, or convulsions ; when the urine 
is suppressed, and when the disease is epidemic. Relapses 
frequently occur. 

AMCEBIC DYSENTERY. 

Amoebic or tropical dysentery, while it may occur in tem- 
perate climates, is not often encountered in this country, espe- 
cially during the earlier years of life. The disease is due to a 
special organism, the amceba coli, and the usual source of in- 
fection is impure drinking-water. 

Morbid Anatomy. — The lesions occupying the colon, and 
sometimes invading the ileum, consist, in the beginning, of 
small elevations, due to infiltration, in the submucosa ; next, 
the mucous membrane covering them sloughs, leaving gray- 
ish-yellow ulcers. Councilman divides these ulcers into four 
varieties, representing different stages of the same process : 
"(i) Ulcers characterized by cellular infiltration, softening, 
and cavity formation in the submucosa ; these have a small 
opening in the mucous membrane and often communicate 
with neighboring ulcers by passages in the submucosa. (2) 
Ulcers with slight undermining of the edges, representing 
simple excavations in the thickened submucous tissue. (3) 
Ulcers with smooth sides and clean bases. (4) Ulcers with 
extensive, adhering sloughs." The products of purulent in- 
flammation are absent, the connective-tissue cells are prolifer- 
ated, and amoebae are found at the base of and about the 
ulcers, in the lymphatic spaces, and sometimes in the blood- 
vessels. In addition to the changes in the intestines, the liver 
is the seat either of scattered local necroses of the paren- 
chyma, or of abscesses, which may be single or multiple. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 313 

Symptoms. — These may develop gradually or — the rule 
in severe cases — suddenly. There is moderate fever, some- 
times nausea and vomiting, often tormina and tenesmus, and 
diarrhoea, the evacuations averaging ten or twelve daily, being 
grayish-yellow in color, containing mucus and blood, and 
showing under the microscope numerous amoebae. The diar- 
rhoea shows a marked tendency to intermit. There is progres- 
sive loss of strength and flesh. 

Diagnosis. — The frequent exacerbations and remissions of 
the diarrhoea and the presence of amoebae in the stools readily 
distinguish this form from catarrhal dysentery. 

Prognosis. — The outlook is less favorable than that of the 
ordinary form of ileo-colitis ; at the best, the disease runs a 
course of from one to three months ; and recovery is slow. 
The beginning of convalescence is indicated by the disappear- 
ance of the amoebae from the evacuations. 

MEMBRANOUS DYSENTERY. 

This, by far the most serious form of ileo-colitis, is fortu- 
nately a rare disease in children, though it may arise, infants 
between the sixth and twenty-fourth month being the usual 
subjects. It may attack the most robust, and is most fre- 
quently unassociated with the deposition of false membrane in 
other portions of the body. 

Morbid Anatomy. — The lesions involve the colon and 
lower part of the ileum, and are most marked near the ileo- 
caecal valve or in the sigmoid flexure and rectum. The intes- 
tinal wall is thickened and indurated ; the pseudo-membrane 
appears in patches, grayish-green in color and often lobulated 
by fissures, and the uncovered mucous membrane is deep red, 
rough, and granular ; the villi, Peyer's patches, and solitary 
follicles are obliterated. The membrane is composed of a 
fibrinous network filled with small round cells, a few red 
blood corpuscles, and bacteria — mainly cocci ; round cells and 



3 H DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

a fibrinous exudate may also infiltrate the mucosa and sub- 
mucosa. 

Symptoms. — The features closely resemble those of the 
severest types of ordinary dysentery, and the course is active 
and brief, extending over a period of from six to ten days. 
The onset is sudden, with sick stomach, high fever, and a 
number of copious liquid evacuations from the bowels. The 
vomiting may cease after the first day, and the temperature, 
originally ranging from 103 to 105 , may continue high or 
remit. Prostration, delirium, or stupor are decided, sometimes 
sufficiently so to mask the intestinal symptoms. There is 
severe abdominal pain and persistent tenesmus ; the latter 
may force through the anus several inches of the rectal 
mucous membrane, which appears as an intensely congested 
mass mottled with patches of pseudo-membrane. The evacu- 
ations are like those of catarrhal dysentery, but blood is 
present more constantly and in greater quantity, and they 
contain shreds and patches of membrane. 

The diagnosis is established by inspection of the stools and 
the discovery of the false membrane. 

The prognosis is unfavorable, almost every case occurring 
in infancy terminating fatally. In older children there is 
more prospect of recovery, but this result is not attained 
until after a long illness and protracted convalescence. 

Treatment. — Children suffering from ileo-colitis must be 
kept at rest in the best room — so far as sanitary conditions 
are concerned — that the house affords. During the acute 
stage the feeding must be guided by the same rules that 
govern entero-colitis or infectious diarrhoea ; in protracted 
cases, weak predigested milk mixtures, broths, and beef-juice 
compose the dietary, and if, as is too often the case, the appe- 
tite so fails that insufficient food is taken to sustain life, nour- 
ishment must be introduced by gavage. To avoid relapse it 



AFFECTIONS OF THE STOMACH AND INTESTINES. 3 I 5 

is necessary to guard the diet carefully long after the estab- 
lishment of apparent convalescence. 

Two or three times daily the body should be thoroughly 
sponged with water at a temperature of 95 ° F., and the ab- 
domen must be kept covered with a light flaxseed poultice, 
over the surface of which a little mustard has been sprinkled ; 
this must be covered with oiled silk and changed as often as 
it becomes cold. 

Irrigation of the colon is the most useful element of treat- 
ment. A normal saline solution should be employed and 
introduced high up in the colon through a long rectal tube ; 
little force must be exerted, but the quantity of solution used 
must be large, — four quarts, — the excess being allowed to 
flow r away during the injection. Two irrigations daily are 
necessary in the beginning ; later, once each day or even less 
frequently is sufficient. Ordinarily the solution may be used 
at a temperature of 98 ° F., though if there be severe tenes- 
mus or a free discharge of blood it should be hot, ioo° F., 
or ice cold. In protracted cases astringent injections are in- 
dicated ; for example, tannic acid 5ss, fluid extract of hama- 
melis foj to one pint of water. More powerful astringents, 
as nitrate of silver, must never be employed in the acute stage 
of a catarrhal attack, and their utility is doubtful even in 
chronic cases. 

In amoebic dysentery injections of a solution of quinine, 
1 : 5000 to I : 1000, are recommended. The patient should 
be placed in the knee-chest position, one-half to one pint of 
quinine solution should be then introduced and allowed to 
remain for fifteen minutes. These injections should be given 
three times each day. 

In membranous ileo-colitis, weak nitrate of silver enemata — 
gr. j to f§ij — may be of service. This quantity may be in- 
jected twice daily for three days and then a free interval of 
twenty -four hours allowed. 



3l6 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

If the patient be seen early in the attack, the medicinal 
treatment may be begun with a laxative, as : 

ft. 01. ricini, f^iv 

Pulv. acaciae, 3 ij 

Tr. opii, rry^viij 

Aq. menth. pip., q. s. ad f^ij. M. 

Sig. — One teaspoonful every three hours, at three years of age. 

After this has been continued for twenty-four hours, there 
should be marked improvement in the evacuations. If this 
be not the case, it is well to order the following : 

fjt . Pulv. ipecac, comp., gr. vj 

Bismuthi subcarb. , ^j 

Pulv. aromat., gr. vj. 

M. et ft. chart.' No. xij. 

SiG. — One powder every three hours. 

If the castor-oil mixture can not be retained on account of 
gastric irritability, calomel in broken doses or a saline cathar- 
tic must be administered, to thoroughly clear out the intes- 
tines. 

If the Dover's powder is badly retained, bismuth may be 
given by itself and the pain and tenesmus relieved by an 
enema of laudanum — gtt. iij-v to f§ss of warm starch-water 
every four hours ; or a suppository of opium and acetate of 
lead : 

ri . Pulv. opii, gr. ss 

Plumbi acetat., gr. j 

01. theobromae, gj. 

M. et ft. supposit., No. vj. 

Sig. — One to be used every four or six hours. 

Cocain by suppository also acts quickly and efficiently. 

To ward off prostration, it is necessary to employ, stimu- 
lants, in doses and at intervals proportionate to the demands 
of the case. Should collapse occur, alcohol and artificial 



AFFECTIONS OF THE STOMACH AND INTESTINES. 3 1 7 

heat to maintain the body temperature are the main re- 
sources. 

When convalescence is established, it is still necessary, as 
already indicated, to guard the diet carefully and at the same 
time to build up the general health by change of air and 
tonics. Of the latter, the best are quinine with dilute nitro- 
muriatic acid, or tincture of nux vomica with compound tinc- 
ture of gentian, followed by ferrated elixir of cinchona, or 
citrate of iron and quinine. 



PROCTITIS. 

Children suffer from several forms of inflammation of the 
rectum : viz., the catarrhal, the membranous, or the ulcera- 
tive ; it is to the first alone that attention need be specially 
directed. 

A severe grade of acute catarrhal inflammation of the mu- 
cous membrane of the rectum and lower portion of the colon 
is of frequent occurrence during the earlier months of infancy, 
and produces symptoms which, without careful analysis and 
local inspection, are misleading and prone to suggest mis- 
directed and unavailing treatment. 

Etiology. — Catarrhal proctitis is most apt to exist as an 
isolated affection in early life, and is more common in arti- 
ficially fed infants, though it often attacks those reared at the 
breast. It is due to direct bacterial infection, or to mechanical 
irritation, resulting from the employment of irritating enemata 
or suppositories, or from the rough or careless use of a soap 
stick or syringe nozle to relieve constipation. In older chil- 
dren it is usually associated with more or less acute catarrh 
of the whole intestinal tract, and is a secondary condition, 
induced by the irritating or infective character of the faecal 
discharges. 

Symptoms. — Proctitis may be suspected if, while the little 



3 1 8 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

patient has a clean tongue, a fair appetite, and retentive stomach, 
there is restlessness, slight febrile reaction, moderately marked 
features of general health failure in the way of wasting, pallor, 
and prostration, and a history of increasingly frequent, small 
bowel movements that are expelled by a straining effort, which 
the facial expression and fretful cries show to be painful. In- 
spection reveals redness and excoriation of an extended area 
of the skin about the anus, and if the lower portion of the 
rectum be everted, — a feat easily accomplished by lateral 
pressure of the thumbs placed on either side of the anus, — 
the exposed mucous membrane shows intense redness and 
often superficial linear ulcerations. The faecal evacuations 
number from ten to fifteen or twenty in twenty-four hours and 
are quite characteristic. Three or four times daily, at moder- 
ately regular intervals, a free, yellow, and almost normal stool 
is voided. The remaining passages are small, scarcely more 
than one or two teaspoonfuls in bulk, are composed almost 
entirely of greenish or dark yellow mucus, are voided with a 
"spurt," and their expulsion is attended by considerable 
straining and crying, symptoms which are almost entirely 
absent at the time the free actions occur. 

When the general intestinal tract is uninvolved in the 
catarrh, the abdomen is normal in size, and soft and painless 
on palpation. 

Diagnosis. — Proctitis is most frequently confounded with 
ordinary catarrhal diarrhoea due to improper feeding, and the 
greater number of cases that have come under my own obser- 
vation have been brought to me because they obstinately 
resisted both the dietetic and therapeutic treatment usually 
successful in this disorder. The error may be avoided by 
noting that each day, at quite regular intervals, there are 
several nearly normal evacuations of the bowels ; that the 
remainder of the evacuations are small in bulk, are composed 
entirely of mucus, and are spurted from the rectum with pain 



AFFECTIONS OF THE STOMACH AND INTESTINES. 319 

and straining ; and, finally, examination shows excoriation of 
the skin about the anus and inflammation of the mucous 
membrane of the rectum. 

Prognosis. — The outlook is very favorable and the course 
is short, provided the proper measures for relief are em- 
ployed. 

Treatment. — This condition is most successfully and 
quickly righted by deep cleansing injections. Usually a solu- 
tion of salt and water (5j to Oj), warmed to a temperature of 
98 °, is all that is required. A fountain syringe is the best 
instrument to employ, and in giving the injection the reservoir 
should be elevated only so high that the fluid will run into 
the gut freely, not forcibly. Of the solution, from four ounces 
to a pint may be used at each washing ; in other words, enough 
to thoroughly cleanse the rectum. These washings may with 
advantage be immediately followed by bland enemata, as olive 
oil or olive oil combined with lime water, in quantities small 
enough to be readily retained — two fluidrachms, for example. 

In very obstinate and chronic cases it is sometimes neces- 
sary to begin the local treatment by injections of nitrate of 
silver. For this purpose a solution of one-half to one grain 
of the nitrate to each fluidounce of distilled water is sufficiently 
strong, and two fluidounces is the usual quantity for each 
injection. Before injecting the silver solution the gut should 
be thoroughly cleansed by a simple warm water enema, and 
five or ten minutes after its introduction a free re-washing 
with a solution of salt and water must be effected in order to 
completely remove or neutralize any excess of the silver salt. 
From one to three nitrate of silver injections, given at inter- 
vals of three or four days, usually suffice to start the repara- 
tive process, which is then readily carried to a successful issue 
by the simpler treatment already detailed. 

To relieve the irritation of the skin around the anus it is 
important to forbid the use of water in cleaning the parts 



320 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

after an evacuation, using in its place olive oil soaked into 
pledgets of absorbent cotton. Oxide of zinc ointment and 
the preparation known as jelly of witch-hazel are useful heal- 
ing applications. 

The general treatment demands only regulation of the food 
supply and attention to the other hygienic requirements of the 
infant and mother. If there be evidences of impaired gastric 
or intestinal function, pepsin or pancreatin are indicated ; an 
occasional laxative dose of castor oil may be necessary, and 
perhaps, toward the end of the attack, a tonic. 



COLIC. 

Colicky pains frequently attend dysentery, constipation, 
and other intestinal disorders ; but colic with flatulence so 
uniformly occurs as a functional affection in children from 
birth to the end of the third month, and gives so much dis- 
comfort both to the infant and its attendants, by causing fret- 
fulness, crying, and wakefulness, that it demands separate 
consideration. 

Etiology. — In studying the causation of this condition, it 
must be remembered that after birth the infant, previously 
nourished through the blood of its mother, begins to take 
food through a new channel. Hence a new habit has to be 
formed, in addition to the development of a secreting and 
absorbing apparatus hitherto inactive. It is during this 
transition state that food even of the best quality may be 
imperfectly or slowly digested and flatulence and colic re- 
sult. 

Food that is at all difficult to digest almost always occasions 
colic, and hand-fed babies are especially liable to it. Other 
causes are fulness of the stomach in overfeeding, or the 
opposite condition of emptiness after nursing at a breast that 
affords milk in small quantity, and, finally, inherited feeble- 



AFFECTIONS OF THE STOMACH AND INTESTINES. 32 I 

ness of digestive power, and oversensitiveness of the mucous 
membrane to the contact of food. 

Symptoms. — Soon after feeding, the infant becomes rest- 
less, kicks his legs about uneasily, twists his body, grunts, or 
utters a series of piercing cries. The face is congested at 
first, from the effort oi crying, but soon becomes pale, with a 
tinge of blue around the lips. The belly is full and hard, the 
hands and feet are cold, and, in bad cases, the fontanelle is 
more or less depressed. After a time, varying from a few 
minutes to an hour, eructations of flatus or of curdled milk 
occur, and the symptoms disappear for a while. Such 
paroxysms may occur at an\- hour of the day, but are most 
frequent and severe in the evening and night. 

There is usually, also, a moderate degree of constipation, 
or the bowels are irregular. At night the rest is broken by 
uneasy tossing and whimpering, and during sleep a smile or 
an expression of pain often flits over the face ; but, in spite 
of the fretfulness and discomfort, the infant suffers little in 
general health, and increases in flesh and strength almost as 
rapidly as is normal. 

Treatment. — When the infant is fed at a health}' breast, it 
is of great importance to insist upon the rule of feeding only 
at proper intervals, and absolutely to forbid the habit of 
putting the child to the breast whenever it cries. Food will 
be taken whenever it is offered, and the warm milk entering 
the stomach relieves the pain for a time, only, however, to 
increase it later by giving the organ more work to do, and 
filling it with material to undergo fermentation with the pro- 
duction of flatus. Consequenth", it is much better to resort 
to one of the preparations to be hereafter given for the relief 
of the pain. 

Should the child draw but a poor and scant}- supply of 
milk, and the colic be due to emptiness, the breast must be 
supplemented by hand-feeding. Under these circumstances, 



322 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

and when the whole feeding is by bottle, much may be done 
to prevent or relieve the attacks of pain by .attention to 
cleanliness of the feeding apparatus ; by carefully selecting 
the ingredients of the food ; by proper modification, and by 
partial predigestion. A good food for a child from six to 
eight weeks old is : 

Milk, fgiss 

Cream, f,! ss 

Barley water, f^iss 

Fairchild's peptogenic milk powder, g|. 

Predigest at 115° F. for four or six minutes ; cool to 98 before giving. 

If the case be not severe enough to demand predigestion, 
one grain of pancreatin and two grains of bicarbonate of 
sodium added to a properly modified bottle of cream, milk, 
barley water, and milk sugar just at the time of its adminis- 
tration produce good results by aiding intestinal digestion. 

When the bowels are inclined to constipation, the barley 
water may be replaced by a gruel made of ground oatmeal 
(Bethlehem brand). One or two teaspoonfuls of the meal to 
the quantity of water necessary for each bottle is the proper 
proportion. In place of this, a teaspoonful of Mellin's food 
may be added to the requisite quantity of water. 

The belly should be rubbed for five minutes twice a day 
with warm olive oil, and enveloped in a broad flannel binder. 
It is even more important to keep the feet warm, and for this 
purpose thick socks or long woolen stockings should be 
worn, and in bad cases, artificial heat must be applied by hot 
water bottles. 

Medicines are indicated chiefly during the attacks of pain. 
A simple and serviceable prescription is ten drops of gin in a 
teaspoonful of sweetened warm water. Another is : 

& . Sodii bicarb. , gr. xvj 

Syrupi, f.! ss 

Aq. menth. pip., q. s. adf^ij. . M. 

SiG. — One teaspoonful p. r. n. for a child of one month. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 323 

This is rendered more efficient by the addition of two drops 
of aromatic spirit of ammonia to each dose, or, in severe cases, 
one drop of spirit of chloroform. 

Bromide of potassium and chloral are most useful ; they 
may be combined as follows : 

& . Potassii bromidi, gr. xvj 

Chloral., gr. viij 

Syrupi, ^3 SS 

Aq. menthse pip. , q. s. adf^ij. M. 

SlG. — One teaspoonful for a dose. 

Of this preparation it is rarely necessary to give more than 
two or three doses, at intervals of an hour. It is well to 
reserve this mixture for severe attacks, and in ordinary cases, 
to use the gin or the soda mixture. 

Should the paroxysm be so violent as to lead to depression 
of the fontanelle and threaten collapse, the infant must be 
placed in a warm bath for five minutes ; after being removed 
and carefully dried, he must be wrapped in a blanket ; a flax- 
seed poultice with a dash of mustard placed over the abdo- 
men ; a hot-water bottle applied to the feet ; the bowels 
relieved by an enema of warm water, and ten drops of gin or 
brandy in warm water administered by the mouth. If the 
fontanelle still remains depressed, the stimulant must be con- 
tinued in doses and at intervals proportioned to the urgency 
of the symptoms ; at the same time the soda and ammonia 
mixture may be given, and a suppository containing one-half to 
one grain of asafcetida inserted in the rectum every fourth hour. 

As a routine treatment to improve digestion, it is well to 
order fifteen drops of essence of pepsin (Fairchild's) three times 
daily. 

HABITUAL CONSTIPATION. 

In addition to the locking of the bowels that results from 
mechanical causes, as intussusception, peritoneal adhesions, 



324 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

and so on, or from paralysis of the muscular coat of the intes- 
tine in certain nervous diseases, constipation of a functional 
character is a frequent and often an obstinate condition during 
childhood. 

Etiology. — Before the completion of the first dentition, it 
is more common in hand-fed babies than those nursed at the 
breast, and is due to the use of milk over-rich in casein ; the 
abuse of starchy food ; an insufficient supply of water, and 
often to the action of popular remedies given to relieve colic. 
With children who have passed the first dentition, constipation 
arises from faulty habits, and from the employment of a diet 
that is either bad in quality or unsuitable from its too great 
sameness. In all cases inherited sluggishness of the peristal- 
tic movements must be remembered as a possible cause. 

Symptoms. — These vary greatly in degree. Thus, an 
infant, instead of the normal number, may have but one 
evacuation a day, or one, two, and even three days may inter- 
vene between the movements. The stools are scanty ; com- 
posed of hard, dry, whitish lumps, and are voided with much 
pain and straining. Should the last symptom be severe, it is 
frequently attended by rectal prolapse and hemorrhage. Other 
features are colic, abdominal distention, diminished appetite, 
occasional vomiting, feverishness, fretfulness, restless sleep, 
and, in bad cases, convulsions. 

In older children there may be one scanty passage each 
day, or a week at a time may elapse without relief. The 
stools, while lumpy and hard, are dark-colored and mixed 
with mucus. The abdomen is the seat of pain, and may or 
may not be distended with flatus ; in the latter event, palpa- 
tion often reveals the presence of hard masses along the course 
of the descending colon. The tongue is coated ; the appetite 
capricious ; there is nausea and a sensation of discomfort in 
the rectum, leading to frequent, though unproductive, strain- 
ing efforts at defecation. There is also languor, irritability of 



AFFECTIONS OF THE STOMACH AND INTESTINES. 325 

temper, headache, and restless sleep ; a muddy complexion 
and general spareness of frame. In some cases the constipa- 
tion seems to be due to simple want of rectal expulsive power, 
as the evacuations, when started by such mechanical means as 
a soap stick, are voided freely and appear to be completely 
digested and are of normal color and consistence. 

Diagnosis. — There is little difficulty in establishing the 
existence of habitual constipation. One must be cautious, 
however, not to place too much reliance upon the statement 
that " the child's bowels are open every day," for in obstinate 
cases, it is not unusual for daily evacuations of thin, worm- 
like masses to take place whilst the bulky and hard faeces are 
retained. 

Prognosis. — Constipation is often a very tedious condition, 
but proper persistent management rarely fails in regulating the 
action of the bowels. It may, however, prove serious in two 
ways : first, by leading to faecal accumulation ; second, by 
generating a condition of general ill health, during which the 
child is more exposed to the attack of acute and dangerous 
disease. 

Treatment. — In every case the relief of the actual state of 
retention of faeces in the rectum and the breaking up of the 
costive habit are the ends to be accomplished. 

For the former purpose, I prefer the use of purgative ene- 
mata and suppositories to the administration of the same class 
of remedies by the mouth, particularly when abdominal pal- 
pation or digital examination of the rectum shows that the 
retained mass is large and hard. The author's plan is to 
inject into the rectum, according to the age of the patient, 
from one to four teaspoonfuls of warm sweet oil ; allow it to 
remain for six hours, and then use one or more clysters of 
normal saline solution, or of olive oil, soap, and warm water. 
The preliminary injections of oil soften the faeces, while the 
clysters — which must vary in bulk from one to six fluid- 



326 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

ounces, to be adapted to the capacity of the gut — have the 
additional effect of distending the walls of the rectum, and 
thus bring about muscular contraction and expulsion of its 
contents. Should the mass present at the anus but be too 
bulky to escape, more liquid may be injected, and if this fail, 
it must be broken up by the finger and its passage assisted by 
gently supporting the perineum during the straining efforts. 
In severe cases little result may follow a single application of 
this method, though a course of one or two oil injections and 
purgative clysters daily for several successive days will rarely 
fail to empty the bowel. 

When the simple injections fail to produce expulsive efforts, 
they may be rendered more efficient by the addition of a tea- 
spoonful or more of castor oil or oil of turpentine. To make 
such an enema for a child of two years : 

Take — One teaspoonful of oil of turpentine, 

Two teaspoonfuls of olive oil, 

The yolk of one egg. 
Mix thoroughly, and add, with constant stirring, to 

Four fluidounces of warm water. 

Another enema which rarely fails to act quickly and effi- 
ciently is from one to two fluidrachms of pure glycerin with 
a fluidounce of water. 

All injections must be thrown in gently, and the action of 
the syringe stopped as soon as pain is produced. 

In infants, unless the rectum be very full, clysters give no 
better results, and are far less convenient than suppositories. 
At the age of two months the following prescription may be 
ordered : 

I£. Saponis, . . . : gr. vj 

Olei theobromae, gj. 

M. et ft. supposit. No. vj. 
SlG. — One to be inserted every morning or morning and evening. 

Or a small glycerin suppository may be used. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 2) 2 7 

Careful regulation of the diet is often all that is required to 
remove the tendency to constipation, and is a most important 
element of the treatment even in those cases where it is neces- 
sary to call in the aid of medicines. 

Bottle-fed babies must be fed upon cows' milk, so modified 
by the addition of cream, sugar of milk, and water as to be as 
nearly like human milk as possible ; and, should the bowels 
still remain confined, some laxative article, as Mellin's food or 
oatmeal, can be added. An admirable mixture for a child of 
three months is : 

Milk, fgij 

Cream, f^ ss 

Sugar of milk, . . gj 

Bethlehem oatmeal (fine powder), g ij 

Water, f^iss. 

In preparing this, the water must be heated — just short of 
boiling — in a tin vessel, and the oatmeal added slowly, with 
stirring, until a smooth, white mixture is obtained ; the other 
ingredients are then to be added, and the whole administered 
from a perfectly clean feeding-bottle. It is usually unneces- 
sary to add the oatmeal to every bottle ; one or two meals of 
it, each day, being sufficient. Or : 

Cream, I tablespoonful (f^ss) 

Milk, 4 tablespoonfuls (f^ij) 

Milk sugar, m . . . .... I teaspoonful (gj) 

Phosphate of sodium, 2 grains (gr. ij) 

Wheat water, • • 3 tablespoonfuls (f^iss). 

To make wheat water, add to I pint of water I or 2 table- 
spoonfuls (according to effect desired) of thoroughly cooked 
cracked-wheat porridge, heat a little short of the boiling- 
point, stir constantly until a mixture is obtained, and strain. 
Dissolve phosphate of sodium in a teaspoonful of hot water, 
and add to food just before administration. One or more 
feedings as required. Encourage infant to take water. 



328 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Often, if the infant's digestive powers will permit of it, 
constipation may be overcome by simply increasing the quan- 
tity of cream in each portion of food. 

During childhood the food selected must be of good quality, 
thoroughly digestible and varied. Starches and meat are to 
be allowed in moderation ; pastry, salt meat, and sweets for- 
bidden, and a judicious use made of such articles as cream, 
oatmeal or cracked wheat in the form of mush, well-cooked 
spinach, celery, cabbage, and peas, baked apples, stewed 
prunes, thoroughly ripe peaches and pears, or the juice of 
oranges. For example, for a child from eighteen months to 
two and a half years : 

First meal, 7 a. m. — A breakfast-cupful (fgviij) of new milk, 
with an additional tablespoonful (f gss) of cream ; 2 to 4 table- 
spoonfuls of thoroughly cooked oatmeal or cracked-wheat 
porridge, with cream and salt ; two slices of whole-wheat or 
bran bread, buttered ; the juice of a ripe orange, or half of a 
moderate-sized ripe apple scraped with a spoon, or a small 
ripe pear, scraped, or a peach. 

Second meal, 1 1 a. m. — A teacupful (f gvj) of milk, with an 
additional tablespoonful (f Sss) of cream ; a slice of bran 
bread. 

Third meal, 2 p. m. — A breakfast-cupful (fgviij) of mutton- 
or chicken -broth, or 1 or 2 tablespoonfuls of underdone roast 
mutton, or beef, or chicken minced fine and pounded to a 
paste ; puree of spinach ; mashed cauliflower-tops ; aspara- 
gus-tops ; stewed celery ; whole-wheat or bran bread, but- 
tered ; junket and cream ; rice-and-milk pudding with stewed- 
prune juice ; baked apple with cream. 

Fourth meal, 6.30 p. m. — Milk, one or two breakfast-cupfuls 
(fSviij-xvj), with additional cream ; whole-wheat or bran 
bread, buttered ; stewed fruit. 

For drink, pure water only. No condiment but salt. 

To encourage peristalsis, warm sweet oil may be gently 



AFFECTIONS OF THE STOMACH AND INTESTINES. 329 

rubbed into the skin of the infant's abdomen for ten minutes 
twice daily, the natural course of the colon being followed ; 
and with children more advanced in age, cool spongings of 
the belly, followed by frictions with a coarse towel until the 
surface is red, are very beneficial. Regular habits for evacua- 
tion, as regards time of day, must be encouraged. 

The ordinary cathartics, castor oil and rhubarb, are not 
adapted to the treatment of habitual constipation, because their 
primary laxative action is followed by a secondary astringent 
effect, and they consequently increase the original trouble. 
There are, however, other medicines of the same class that 
are free from this disadvantage, and one of them, or, better, a 
combination of several of them, may be employed. 

For infants a very serviceable prescription is : 

H . Mannce opt., 

Magnesii carb. , aa % ij 

Ext. sennoe fid., ^S ss 

Syrupi, - - f.?j 

Aq. rnenth. pip., q. s. ad f^iij. M. 

SiG. — A teaspoonful once, twice, or three times daily for a child of six 
months. 

Or should a sallow skin, yellowish conjunctivae, and loaded 
tongue indicate torpor of the liver : 

& . Resinre podophylli, gr. ss-j 

Alcohol, rr^xlviij 

Syrupi, q. s. ad f^iij. M. 

SiG. — A teaspoonful two or three times daily for a child of one year. 

If it be difficult to make the infant take medicine, manna — 
which imparts only a sweet taste — may be dissolved in the 
food, and given from the bottle as often as required. Phos- 
phate of sodium — an admirable laxative — can also be adminis- 
tered in the same way, in doses of two to five grains three 
times each day, at the age of six months. 

Children of three or four years and upward do best upon 
28 



330 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

aloes and belladonna. Tincture of aloes and myrrh in doses 
of five drops thrice daily, or in a single dose of ten drops at 
bedtime, acts well ; but if the patient be old enough to swal- 
low a pill, the following prescription is to be preferred : 

K . Ext. belladonna?, gr. ss 

Pil. aloes et myrrh., gr. xij 

01. cari, gtt. iij 

Ext. taraxaci, gr. xij. 

M. et ft. pil. No. xij. 

SiG. — One pill at bedtime for a child of six years. 

Or the aloes and belladonna may be combined in a mix- 
ture,* thus : 

R . Tr. belladonna?, Tr\^xij 

Tr. aloes et myrrh., ^3 SS 

Mucilag. acacise, q. s. 

Aquse menth. pip., q. s. ad f^ iij. M. 

SiG. — One teaspoonful for a dose. 

In using aloes and myrrh, it is usually necessary to reduce 
the dose after a time, as its purgative action increases rather 
than diminishes with repetition. 

Another useful laxative is cascara, in the form of a fluid 
extract or an elixir ; of the first preparation ten drops, of the 
second, twenty drops may be given, once or several times 
daily to a child of six. It does not quickly lose its effects by 
repetition. 

I have lately used with much satisfaction a laxative confec- 

* A clearer mixture may be made by using a solution of aloes and myrrh in- 
stead of the officinal tincture. The following is the formula : 

- R. Aloes, 

Myrrha?, aa gr. iiss 

Alcohol, f^ss 

Glycerini, f^j 

Aqua?, q. s. ad f^iij. M. 

This solution was compounded, at the author's request, by Mr. J. J. Ottinger, 
of Philadelphia. The dose is the same as the tincture. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 33 1 

tion, composed of tamarind pulp (gr. xxxvj) and senna in 
powder (gr. iv), aromatized with aniseed and lemon, and acid- 
ulated with tartaric acid. One of these may be eaten every 
evening, or as often as necessary, by a child three years of age. 
They are regarded as sweets rather than medicine, and the 
little patients eat them readily. 



APPENDICITIS. 

Under this heading is now included those inflammatory con- 
ditions about the caecum which were formerly classed as 
" typhlitis " or " caecitis," " perityphlitis," and " perityphlitic 
abscess." Typhlitis as an independent lesion undoubtedly 
does occur, but it is a comparatively rare condition, and, 
probably, is always secondary to faecal impaction. Appendi- 
ceal inflammation maybe either catarrhal or ulcerative in form 
and its course may be acute, or chronic and recurrent. 

Morbid Anatomy. — The lesions are usually seated in the 
right iliac fossa, but they are no more fixed in position than 
the appendix itself, which may lie away from its normal place, 
and be in the pelvis, in the region of the kidney, or in the 
neighborhood of the umbilicus. In the catarrhal form the 
walls of the appendix are thickened by cell infiltration, its 
caecal orifice is closed, it is markedly distended by mucus, pus, 
and faeces or other foreign matter, and its peritoneal surface 
is congested. This condition may disappear without further 
trouble, or it may, especially after repeated attacks, produce 
ulceration and perforation. 

Typhoid fever and tuberculosis of the intestines may be 
attended by appendiceal ulceration, but the term ulcerative or 
perforative appendicitis covers only the form due to inflamma- 
tion excited by a foreign body within the appendix. In some 
cases the ulceration gradually effects a small perforation ; in 
others the appendix becomes overdistended by the products 



332 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

of inflammation and gangrene sets in with the sudden produc- 
tion of a large opening. The consequences of this perforation 
depend upon the rapidity of its occurrence and upon the 
position of the appendix ; that is, whether or not it is so 
situated that adhesions are readily formed. If the perforation 
takes place slowly, the' general peritoneal cavity is protected 
by an exudate of lymph about the appendix ; if suddenly, 
there is an immediate congestion or beginning inflammation 
of the entire peritoneum ; this, when the appendix is favorably 
situated, is soon limited by plastic adhesions. If infective 
material has escaped, at the time of perforation, an abscess 
forms ; if not, the result is a localized plastic peritonitis. 
The seat of the abscess depends upon the position of the 
appendix ; usually it is in the right iliac fossa, but it may be 
in the pelvic cavity or in the lumbar region. The abscess, in 
the absence of surgical interference, tends to open externally, 
into the rectum or other portion of the intestinal canal, or 
into the peritoneal cavity ; in the latter case setting up a 
general peritonitis. When the position of the appendix is 
such that adhesions cannot form about it, or if these be 
absent or incomplete, sudden perforation gives rise to septic 
peritonitis with all its dangers. 

The foreign bodies or appendiceal concretions resemble in 
shape and size cherry or date stones. They are hard, often 
laminated in structure, have a smooth, waxy-looking sur- 
face, are grayish or brown in color, and are composed of 
earthy phosphates combined with inspissated mucus and 
faecal matter. Pins, shot, splinters of bone, strawberry seeds, 
hairs, and little masses of hardened mucus, may form the 
nuclei of these calculi. 

Hepatic abscess, pyaemia, empyema, and pneumonia may 
follow perforative appendicitis. 

Etiology. — Appendicitis is not, strictly speaking, an affec- 
tion of childhood ; nevertheless children between four and 



AFFECTIONS OF THE STOMACH AND INTESTINES. 333 

twelve years of age are liable, particularly to the perforative 
form ; it occurs with greater frequency in boys than in girls. 
A constipated habit is the chief predisposing cause. In this 
class, too, may be placed obstinate diarrhoea and intestinal 
disorders generally. The existence of the tuberculous 
diathesis, too, while it has little influence in increasing the 
susceptibility to appendicitis, does augment the tendency to 
ulceration and perforation after inflammation is established. 

Retention of hardened faecal matter in the caecum, the 
so-called " typhlitis stercoralis " ; accumulation of the seeds 
of certain fruits, as strawberries or raspberries, in one of the 
pouches of the caecum ; the passage of these, or of faecal 
concretions or foreign bodies, — shot, pins, and bone spiculae, 
— into the appendix, and the habitual use of coarse, indiges- 
tible food, are the most common excitants. Cold and 
exposure, blows upon the abdomen, violent exertion with 
strain of the abdominal muscles, and the abuse of drastic 
cathartics, are also sometimes determining causes. 

The bacterial cause of appendicitis is, probably, the bac- 
terium coli commune ; this germ is constantly present in the 
intestinal canal, and has little or no influence upon a sound 
mucous membrane, but, given destruction of the epithelium, 
it has pathological and pyogenic properties. 

Symptoms. — Catarrhal appendicitis presents rather ob- 
scure symptoms. The patient is frequently not ill enough to 
make complaint or to be confined to bed, and the condition 
probably often passes to recovery without being recognized. 
The characteristic symptoms are moderate pain in the caecal 
region, with tenderness on pressure, most decided at McBur- 
ney's point ; sometimes vomiting ; constipation, and moderate 
elevation of temperature, the mercury rarely ranging above 
101 F. 

Perforative appendicitis develops, as a rule, after the ill- 
defined features of the catarrhal form have been present for 



334 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

several days. It begins suddenly, with pain in the right iliac 
region and vomiting, and sometimes with a chill. The pain 
is constant and severe, and is increased by coughing, sneezing, 
vomiting, and by efforts to stand or walk. While generally 
limited to the caecal region, it may be reflected to the navel, 
or even be most marked on the left side of the abdomen. 
The vomiting is attended by distressing retching ; is often 
repeated, and the ejections consist, first, of food, and after- 
ward of bile-stained fluid. The patient has an anxious face 
and the appearance of serious illness ; lies on his back slightly 
inclined to the right side, with the right thigh drawn up, and 
complains if an attempt be made to straighten it. Abdominal 
respiratory movements are partially suppressed ; the right iliac 
region is full and even prominent, very tender to the touch, 
dull on percussion, and the abdominal wall is more or less 
rigid. Palpation, when it can be practised, reveals a resistant 
mass occupying the right iliac fossa. There is fever, indicated 
by a coated tongue, extreme thirst, a frequent and somewhat 
wiry pulse, and "a temperature ranging about ioi° or 102 F. 
The bowels are confined. 

With these initial symptoms the future course depends 
upon the result of the perforation, whether followed by (a) 
localized plastic peritonitis, (b) localized suppurative peri- 
tonitis, or (c) general peritonitis. 

{a) There is severe pain, tenderness, and diffuse induration 
in the right iliac region ; vomiting ; constipation, and mod- 
erate fever, the temperature ranging from ioo° to 102° F. 
After six or seven days the fever gradually disappears, the 
pain and tenderness abate, and the area of induration dimin- 
ishes, finally leaving a nodulated mass as large as a hen's egg, 
which may not entirely disappear for weeks. Recurrent 
attacks are probable. 

(J?) In some cases of localized suppurative peritonitis, the 
fever, pain, and tenderness of the earlier stages continue and, 



AFFECTIONS OF THE STOMACH AND INTESTINES. 335 

after several days, a distinct tumor may be detected in the 
right iliac fossa and pus may be reached by aspiration or by 
an exploratory incision. In others the acute symptoms sub- 
side, though the temperature does not quite recede to the 
normal point and the pulse is too frequent ; then after an in- 
terval of inactivity, of very variable duration, the temperature 
slowly rises, pain and tenderness become more marked and 
more extended, the indurated mass enlarges and assumes 
greater prominence, suppuration takes place and gradually 
progresses until large quantities of pus accumulate. Occa- 
sionally abscess formation is attended only by slight pain, 
moderate pyrexia, and retraction of the right thigh. 

(V) In these instances the initial symptoms are succeeded 
by those of general peritonitis. Vomiting continues ; tender- 
ness and pain are no longer localized, but extend over the 
whole abdomen ; the bowels are locked and tympanites is 
pronounced. Prostration is rapid and extreme, the pulse 
grows frequent and feeble, the temperature generally ranges 
from 101 to 103 , but may be normal or even subnormal, 
and death, the usual outcome, is preceded by cold sweats, 
hiccough, stercoraceous vomiting, and general collapse. 
Sometimes after the acute onset the symptoms abate, showing 
a tendency to the formation of limiting adhesions, but this 
improvement is of brief duration, the incomplete barriers 
giving way, and the ordinary course is soon resumed. 

Typhlitis Stercoralis is a condition of congestion and tume- 
faction of the caecum due to distention of this portion of the 
gut by faecal accumulation, or by a retained mass of mingled 
faeces and undigested food. While faecal distention of the 
caput coli is often the forerunner of appendicitis, instances 
are not infrequent, especially in children, in which typhlitis 
alone is present, the appendix being quite uninvolved. The 
recognition of such cases is important, as the prognosis is 
much more favorable than in appendiceal inflammation and 



336 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

operative interference is usually unnecessary. The symptoms 
are the initial presence of a doughy, sausage-shaped tumor 
in the right iliac region, moderate tenderness, slight elevation 
of temperature and increased pulse rate, infrequent vomiting, 
and constipation or, occasionally, spurious diarrhoea. The 
diagnostic feature is the initial tumor ; the other symptoms 
are those of appendicitis, the difference being merely in 
degree. 

Recurrent appendicitis of mild type frequently results from 
digestive disorders, and may be produced by one special 
article of food. Several attacks may occur and be followed 
by entire and permanent recovery. 

Chronic relapsing appendicitis differs from the recurrent 
form in that the interval between the attacks is not a period 
of health ; the patient suffers from flatulence, constipation, or 
diarrhoea ; there is pain in the caecal region, increased by ex- 
ercise or fatigue ; the attacks are more acute, are attended by 
the development of a tumor, which may, in fact, never entirely 
disappear, and by the symptoms of localized peritoneal in- 
flammation. Finally, the general health is undermined and 
there is decided anaemia and loss of flesh. 

Diagnosis. — A sudden attack of pain referred to the right 
side of the abdomen ; vomiting ; constipation ; a pinched, anx- 
ious face ; fever ; a dorso-lateral decubitus ; flexion of the right 
thigh, and the presence of an intensely tender tumor in the 
caecal region, with increased resistance of the parietes, are the 
characteristic symptoms of appendicitis. 

Perforative ulceration may be suspected if these symptoms 
disappear and reappear several times, or if, after a free evacua- 
tion of the bowels, the local pain, tenderness, and swelling 
continue. 

A blood count is of great value in establishing the diagnosis 
in obscure cases, the presence of leucocytosis indicating pus 
formation. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 337 

Sometimes it is impossible to differentiate the catarrhal from 
the ulcerative form, as the onset of the former may be acute 
and violent, and perforation may occur without the develop- 
ment of the characteristic symptoms. 

Intussusception resembles typhlitis in some of its features, 
but in this condition tenderness is a late symptom ; the tumor 
is situated more to the left of the abdomen ; sometimes the 
lower end of the invagination can be felt in rectal examination, 
and there is severe tenesmus with the expulsion of blood- 
stained mucus. 

Appendicitis must not be confounded with colic or intestinal 
indigestion in infants, or with local suppuration — the abscess 
of Pott's disease or of psoitis — in the right iliac fossa in older 
children. 

Prognosis. — Many cases of appendicitis, especially the 
catarrhal form, terminate in recovery. The duration of active 
illness is from four to twelve days, though several weeks often 
pass before the local tenderness and induration entirely dis- 
appear, and the functions of the intestine are restored. Recur- 
rence is less apt to occur in children than in adults, and can 
usually be traced to a too early abandonment of treatment and 
resumption of ordinary diet and manner of living. If the cure 
has been thorough, a second attack is not to be particularly 
dreaded. 

In perforative appendicitis the outlook is much less favor- 
able. In cases resulting in the formation of a single, localized 
abscess, recovery is the rule under proper treatment. On the 
contrary, if general peritonitis be set up, at any stage of the 
disease, death must be expected, though by prompt surgical 
intervention a life may be occasionally saved. 

In tuberculous patients the prognosis is always less favor- 
able than in others. 

Treatment. — For prevention, it is necessary to guard 
against habitual constipation, by a properly selected diet, by 



33$ DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

regular exercise, and by enforcing the rule of making daily 
attempts to evacuate the bowels at a fixed hour. Nature may 
be assisted by a teaspoonful of compound licorice powder at 
bedtime, or one of the following pills : 

$ . Resinse podophylli, gr. iss 

Ext. belladonnae, gr. j 

Ext. taraxaci, gr. xij. 

M. et ft. pil. No. xij. 

Sig. — One pill every night for a child of six years. 

Or— 

U . Ext. belladonnae, 

Ext. nucis vomicae, aa gr. j 

Ext. colocynth. comp. , gr. vj 

01. cari, gtt. iij 

Confec. rosce, gr. vj. 

M. et ft. pil. No. xij. 

SiG. — One pill every night. 

Should there be a tendency to faecal accumulation, the mass 
is to be removed by purgative enemata. One teaspoonful of 
table salt to a pint of warm water will be efficient for this pur- 
pose — assisted by a course of calomel, followed by a saline 
laxative in small, repeated doses. The patient should be 
warmly clothed, especially about the abdomen ; the feet must 
be kept dry, and exposure to cold and dampness avoided. 

A child attacked by appendicitis must be put to bed and 
kept at rest upon the back ; a small pillow may be placed 
under the right knee to support the thigh. The iliac region 
is to be covered with an ice-bag or a hot flaxseed poultice, or, 
if the child be robust and the tenderness and pain excessive, 
two or three leeches may be applied before poulticing. The 
non-retentive condition of the stomach, the inability of the 
involved portion of intestine to care for the little food that can 
be retained, and the necessity of avoiding every source of local 
irritation, all point to restriction of food to the smallest possi- 
ble amount. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 339 

For the first two or three days small quantities of water at 
short intervals — one or two tablespoonfuls even' half-hour — 
should alone be allowed. After pain and tenderness have 
abated and the bowels have been freely moved, cautious feed- 
ing may be begun, with one or two teaspoonfuls of raw-beef 
juice or panopepton every two hours. Later still, and for 
some time, no food but milk, or milk with a little mutton- or 
chicken -broth, is allowable, and these are to be given in small 
quantities at short intervals. A patient six years old may 
take every two hours : 

Milk, f 3 ij 

Barley water, , f 3 i j 

Saccharated solution of lime, gtt. xv. 

Saccharated solution of lime is used as an alkali instead of 
lime water, on account of its adding no bulk to the food ; it is 
prepared in this way : 

Take of — 

Slaked lime, 5J 

Refined sugar, in powder, 3 ij 

Distilled water, f^xyj. 

Mix the lime and sugar by trituration in a mortar ; transfer to a bottle contain- 
ing the distilled water, cork, and shake occasionally for a few hours. Finally, 
separate the clear solution with a siphon and keep in a stoppered bottle. 

When broth is used, it may take the place of milk at three 
or four feedings during the twenty-four hours, or if the milk 
produces pain, the diet must be restricted to broth and beef- 
juice. Whey mixtures and peptonized milk may also be em- 
ployed. 

The medicinal treatment is simple and consists in the ad- 
ministration of saline cathartics in small repeated doses until 
free purgation is produced. Sulphate of magnesium in doses 
of gr. xv-xx every two hours is usually readily tolerated by 
the stomach and is painless and efficient in its action. Citrate 
of magnesium or Rochelle salts may also be used. After the 



34-0 DISEASES OF DIGESTIVE ORGANS IN CHILDREN 

intestines are emptied, the saline should be discontinued and 
the laxative action continued by broken doses of calomel ; 
this has a valuable antiseptic action, and by its effect on the 
portal circulation relieves congestion of the ileo-colic vein and 
its tributaries. The less opium employed, the better ; it is 
only permissible in the event of extreme colicky pains, and 
should be administered either hypodermatically or in supposi- 
tories. 

As soon as convalescence begins, — i. e., when pain, rigidity, 
and local tenderness subside, — the diet may be cautiously 
increased ; a belladonna plaster substituted for the poultices ; 
mild laxatives and tonics administered, and the patient allowed 
to sit up in bed, and after a time, — two or three weeks, — 
as health returns, to be up and about. Very active exertion 
should be avoided for several months. 

If, on the other hand, the symptoms are worse at the end 
of forty-eight hours, or sooner if there be severe, lancinating 
pain, greater tenderness, and rigidity, and either local or gen- 
eral tympanites, the patient must pass from the hands of the 
medical man into those of the surgeon for operative interfer- 
ence. 

Stercoral typhlitis requires the same regimen and medical 
treatment as appendicitis. 

Recurrent appendicitis requires operation when the attacks 
are very frequent and show a tendency to a lessening interval 
and an increasing severity ; but surgical interference must not 
be hasty. 

Chronic relapsing appendicitis usually demands operation. 



INTUSSUSCEPTION. 

In intussusception or invagination one portion of the intes- 
tine is forced, from above downward, into another portion 
immediately continuous with it. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 34 1 

Apart from faecal accumulation, this is practically the sole 
cause of intestinal obstruction in infancy. For, although in- 
stances are on record in which the bowel, in children, has 
been closed by peritoneal adhesions, by a twisted vermiform 
appendix, and by morbid growths, these are but pathological 
curiosities. 

Two forms are met with : namely, intussusception without 
symptoms, and intussusception with symptoms. 

INTUSSUSCEPTION WITHOUT SYMPTOMS. 

This condition, which must be regarded rather as an acci- 
dent than a disease, is frequently encountered in autopsies upon 
young children who have met death from very diverse affec- 
tions. 

Such intussusceptions occur shortly before, or during, the 
death agony, and are probably produced by irregular and vio- 
lent contractions of the muscular fibres of the gut ; occasionally 
they have been observed to occur after death, during autopsy. 
They consist simply of an involution of the bowel, without 
evidence of inflammatory action at the site of lesion, and can 
be readily reduced by traction. Sometimes there is but one 
inversion, though usually there are several ; as many as ten or 
twelve distinct invaginations, at a distance of a few inches from 
each other, having been found in the same subject. The length 
of gut displaced is rarely more than three or four inches. The 
small bowel is the uniform seat ; and of this division of the 
intestines, the lower part of the jejunum and the upper part 
of the ileum are most frequently involved. 

Without a post-mortem examination, it is impossible to recog- 
nize the existence of this form of intussusception, on account 
of the entire absence of symptoms. Nevertheless, its dis- 
covery may be anticipated when death has resulted from 
cerebral or spasmodic diseases, or from acute or chronic 
entero-colitis. 



342 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

INTUSSUSCEPTION WITH SYMPTOMS. 

True intussusception is, fortunately, not very frequently met 
with in children, though it is more common in early infancy 
than in later childhood, youth, or adolescence. 

Morbid Anatomy. — The probable mechanism of an intus- 
susception is that a limited portion of the intestine contracts 
forcibly, and, by elongating and moving forward, enters anon- 
contracted segment immediately below, drawing in more or less 
of the latter, together with its mesentery or meso-colon.* 
Next, new peristaltic movements force the invaginated bowel 
further and further along, until extension is arrested by re- 
sistance from the mesentery, or by secondary inflammatory 
adhesions. The intussusception must, therefore, be made up 
of three layers of intestine, one above the other. The outer 
layer is called the sheath, or intussuscipiens ; the middle and 
inner ones, the intussusceptum. Of these, the external and 
middle have mucous surfaces in contact ; the middle and in- 
ternal, serous surfaces. The involuted mesentery or meso- 
colon lies between the two last-named layers, and, on account 
of the firm attachment at its roots, exerts a one-sided traction 
upon the intussusceptum, curving it upon its axis and draw- 
ing the lower opening — which is elongated to a narrow fis- 
sure — from the centre toward the side of the sheath. The 
sheath itself is much folded or puckered, and on this account, 
with the curving of the intussusceptum, the apparent length 
of gut involved is always much less than the actual length. 
This varies from a few inches to several feet ; in extreme cases 
an intussusception beginning at the ileo-caecal valve may be- 
come apparent to the touch or sight at the anus. Increase in 



* Nothnagel believes that invagination is caused by the normal gut being 
drawn over the spasmodically contracted part, rather than by that being mechan- 
ically driven into its sheath. Treves also calls attention to the influence of the 
longitudinal muscular fibres of the bowel wall, acting from the contracted part 
as from a fixed point, and drawing the unconstricted portion over the other. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 343 

length is accomplished by peristaltic action from behind ; it 
takes place, always, at the expense of the external layer, and 
depends, for its degree, upon the force of peristalsis, the width 
and laxity of the mesentery or meso-colon, and the amount 
and character of the contents of the intestine behind the seat 
of involution. 

The results of an intussusception are, first, occlusion of the 
lumen of the canal with partial, or generally complete, arrest 
in the passage of the intestinal contents ; and, second, obstruc- 
tion of the blood current in the middle and inner tubes, due to 
the pressure upon the mesenteric vessels. The obstruction of 
the circulation leads to deep congestion of the tissues of the 
intussusceptum ; the mass becomes purple and swollen ; the 
mucous surfaces exude a bloody material, and soon the 
opposed serous surfaces are glued together by inflammatory 
adhesions. 

Should there be complete strangulation, the intussusceptum 
becomes gangrenous, and, under favorable circumstances, may 
be detached en masse or in pieces, and discharged through the 
anus. When this occurs, provided firm adhesions have formed, 
the sheath, being united at its upper extremity to the intestine 
directly above the point of inversion, forms with the latter a 
continuous tube, notwithstanding the separation of the inter- 
vening portion. 

Several accidents may happen during this process. Thus, 
the inflammation in the opposed serous coats may extend 
beyond the involution, and give rise to general peritonitis. 
Or, ulceration and perforation of the sheath may be produced 
by the pressure and irritation of the free end of the intussus- 
ceptum. Again, when adhesions are imperfect, the contents 
of the intestine may escape into the peritoneal cavity through 
a rent, resulting from the separation of the sloughing intussus- 
ceptum ; and, finally, even after the gangrenous mass is expelled, 
the adhesions may give way and permit extravasation. 



344 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Generally, in those fortunate cases in which sloughing is fol- 
lowed by recovery, no permanent injury results from the cica- 
trization at the point of junction of the sheath and uninvolved 
intestine. The cicatrix, though at first contracted, gradually 
stretches and a free passage-way is established. 

Sometimes intussusception is attended with so little con- 
striction of the involuted gut that the passage for the con- 
tents of the uninvolved intestine is quite free enough to allow 
of the maintenance of life for months, the patient finally dying 
of exhaustion. 

In infants the invagination is almost invariably ileo-caecal. 
The end of the ileum with the ileo-caecal valve is forced into 
the caecum, and, as the intussusception increases, penetrates 
further and further into the colon, drawing along more of the 
ileum, and doubling in, first, the caecum, and then the ascend- 
ing, or even the transverse and descending, portions of the 
colon. In some cases a few inches of the gut pass through 
the ileo-caecal valve before the caecum is inverted. Occasion- 
ally an intussusception involves the colon alone, and, very 
exceptionally, the small intestine. 

Upon opening the abdomen, in an ordinary case, much of 
the colon appears to be wanting, and a tumor is found occu- 
pying the left side or the left iliac fossa. This mass — the 
intussusception — is slate-gray in color, elongated or sausage- 
shaped, and doughy to the touch. By more or less forcible 
traction, the involution may be reduced, though the gut is 
usually softened and apt to be torn in the effort. If an inci- 
sion be made through the sheath, exposing the intussuscep- 
tum, two orifices will be observed at the lower end of the 
latter, one leading through the valve, the other into the cavity 
of the appendix vermiformis. The invaginated intestine is 
either of a uniform deep red color, resembling a long firm clot 
of blood, or presents the appearances common to gangrenous 
and sloughing tissues. If death has occurred early, there are 



AFFECTIONS OF THE STOMACH AND INTESTINES. 345 

few evidences of inflammation between the serous surfaces ; if 
later, these are adherent, the adhesions extending a few lines 
beyond and above the neck of the intussusceptum on to the 
sound intestine. The gut situated above the point of obstruc- 
tion is usually greatly distended with accumulated faecal mat- 
ter and flatus ; whilst that below is collapsed and empty, or at 
most contains a small quantity of mucus, stained with blood- 
pressed out from the capillaries of the strangulated mass. 

As the age of the child advances the more likely is the 
intussusception to be confined to the small intestine. 

Etiology. — As already indicated, early age seems to act as 
a powerful predisposing cause. Of fifty -two cases in children, 
recorded by J. Lewis Smith, twenty-three occurred between 
the ages of three and six months ; eight between the sixth 
and twelfth months ; and eighteen between the first and twelfth 
years. Of Leichtenstern's four hundred cases, one-fourth 
occurred in the first year, after the third month. The greater 
liability in infancy is due partly to anatomical peculiarities, and 
partly to the want of regularity and the energy of the intes- 
tinal movements. Thus, in infants, the large intestine holds 
to the abdominal space that it is forced to occupy the relation 
of about three to one, necessitating doubling of the gut upon 
itself. At this time of life, too, the meso-colon is much wider 
than in later years, except where it passes over the kidneys, 
in which position it is very narrow, or even almost absent. 
These two conditions, combined with unrhythmical and vio- 
lent peristalsis, cannot but favor involution. 

Many more males are affected than females. Rilliet and 
Barthez record twenty-five cases, all but three in boys, and 
the statistics of other authorities bear out their figures. 

The exciting causes are imperfectly understood. Attacks 

have been attributed both to obstinate diarrhoea and prolonged 

constipation ; to the presence of intestinal worms ; to polypoid 

growths ; to strictures and tumors of the intestine ; to pre- 

29 



346 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

viously existing adhesions ; to the use of irritating and indi- 
gestible food ; and to external violence. 

Symptoms. — These vary considerably, according to the 
age of the sufferer and the completeness of intestinal obstruc- 
tion. 

In patients under one year the onset is abrupt, whether it 
occur in the midst of health, or during the course of some 
derangement of the digestive tract. The child is seized with 
intense pain in the abdomen, turns excessively pale, screams, 
and then cries violently, writhing and drawing up his legs. 
The contents of the stomach are vomited, and usually, unless 
the bowels have been evacuated just before the attack, there is 
a single discharge of somewhat liquid feculent matter. After 
a time the pain passes away, leaving the little sufferer pallid 
and exhausted. There is now a rest from pain, but not from 
vomiting ; all food or medicines taken into the stomach are 
returned at once, either by the easy process of regurgitation, 
or by violent retching ; and if the viscus be empty, the ejec- 
tions consist of a little bile-stained mucus, or even of blood. 
Sooner or later — the interval varying from a few minutes to 
several hours — there is another paroxysm of pain, accom- 
panied by violent tenesmus, resulting in the evacuation of 
blood and mucus. 

At this time the abdomen differs little from its normal con- 
dition. There is no fulness nor tenderness, nor any tumor ap- 
preciable to the touch ; on the contrary, gentle friction often 
relieves the colicky pains, and the child prefers to lie upon its 
belly. The hands and feet may feel cool, though, otherwise, 
the temperature of the surface is unaltered. The mind is clear, 
but the expression of face is anxious, and denotes severe ill- 
ness. The tongue may be lightly furred, and there is increased 
thirst, leading to a greedy consumption of the contents of the 
feeding-bottle or a ravenous sucking at the breast. There is 
also restlessness, constant whining or moaning, and an in- 



AFFECTIONS OF THE STOMACH AND INTESTINES. 347 

ability to sleep. After a period of twelve or twenty-four 
hours, in which the paroxysms of pain and tenesmus have 
grown more frequent and severe, the abdomen becomes full ; 
there is tenderness in the left iliac fossa, and if deep pressure 
be made in this region, during the absence of pain, a distinct 
swelling may be detected. The tumor gradually becomes 
more defined ; it is elongated or sausage-shaped, of doughy 
consistence, and ranges in size from that of a hen's egg to 
that of a clenched fist. Later, it may change its position, 
moving toward the left side. When easily detected by exter- 
nal palpation, the tumor may be touched by a finger inserted 
into the rectum, and under these circumstances feels much 
like the cervix uteri in a vaginal examination. Occasionally 
the lower end of the involuted intestine protrudes from the 
anus, looking not unlike a prolapsed rectum. 

While these features are developing, vomiting continues, 
and bloody mucus is expelled, with great straining, from the 
rectum, but there is no passage of either faeces or flatus. The 
amount of blood varies considerably ; in some cases there is 
no more than sufficient to stain the diapers ; in others, three 
or four ounces are voided several times daily. The tongue is 
red and glazed, or covered with a dry, brown coating ; the 
pulse becomes frequent and feeble ; the temperature rises to 
102 or 103 F. ; the abdominal respiratory play is restricted, 
and the flesh wastes. The urine may be greatly diminished 
in quantity ; this, however, is by no means a constant condi- 
tion, and seems to bear no relation to the seat or extent of the 
intussusception. 

By the third day symptoms of collapse set in. The face 
becomes pinched ; the eyes sunken and surrounded by dark 
circles ; the skin feels cool and clammy, and the thermometer 
indicates a subnormal temperature. The attacks of vomiting 
are less frequent ; the pain less intense ; the bloody evacua- 
tions lessen or disappear, and the child lies upon his back, in 



34-8 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

an apathetic condition, with half-closed eyelids, until the end 
comes at some time between the fourth and sixth day. Occa- 
sionally death is preceded by convulsions. 

If, by any means, the invagination be reduced, the vomiting 
stops, pain disappears, flatus and thin, copious, semi-liquid 
and offensive stools are voided, and the patient finds rest in 
sleep. Afterward there is pallor, languor, and weakness, 
though the appetite quickly returns and flesh and strength 
are soon regained. 

When older children are attacked, the picture differs in 
some of its details. 

Thus, abdominal distention appears earlier and is more 
marked. The gut behind the position of obstruction being 
filled with faeces and flatus, is greatly stretched, and the out- 
line of its coils may be distinctly seen and felt through the 
tense wall of the belly. This is especially the case during the 
paroxysms of pain, when, too, waves of peristalsis may be 
seen, and loud, gurgling sounds heard. The tumor is large 
and better defined, and the dull percussion note that it yields 
contrasts strongly with the general tympany. 

Vomiting is more apt to be stercoraceous. This character- 
istic symptom is absent in many cases, and very naturally so ; 
for, if Brinton's theory be adopted, — namely, that faecal vomit- 
ing is due to a reverse axial current in the contents of the 
intestine, and not to anti-peristalsis, — it is apparent that, for 
the development of this symptom at all, the obstruction must 
be either in the large intestine or in the lower part of the 
ileum. The date of its onset must depend upon the distance 
of the starting-point of the reverse current, or the obstruction, 
from the stomach ; upon the rapidity with which the bowel 
above is filled by ingestion and secretion; and, should the 
colon alone be involved, upon the readiness with which the 
resistance of the ileo-caecal valve is overcome. 

Evacuations of blood are much less uniformly observed. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 349 

Whether this symptom be present or absent depends solely 
upon the degree of constriction of the invaginated bowel. 
When the constriction is just sufficient to obstruct the circu- 
lation and overfill the vessels, hemorrhage is constant ; but 
when there is actual strangulation, with complete arrest of 
circulation, no blood escapes. In older children strangula- 
tion is much more apt to occur than in infants, partly because 
the invagination more frequently involves the ileum or jeju- 
num, — which have a smaller calibre than the colon, — and 
partly from the fact that in them, life being more prolonged 
after the accident, there is greater opportunity for inflamma- 
tory swelling. Hence it is that in this class of cases there is, 
in many instances, absolute constipation without bloody stools, 
though in others, where the intussusception is ileo-caecal or 
colic, hemorrhage from the anus may be noticed as an early 
and permanent feature. 

The blood appears in a liquid form, mixed with mucus, or 
in small clots. It always has the venous hue, and is darker 
in color and smaller in quantity, in proportion to the distance 
of the involution from the anus. 

The older the child, the more likely is gangrene, separation, 
and elimination of the invaginated gut to take place. This 
result is usually noted during the course of the second week 
of illness, and can be attributed to the greater power of resist- 
ance and tenacity of life displayed by older children than by 
infants. It is a fortunate ending, but, unfortunately, rarely oc- 
curs at any age. After the process of separation is completed, 
violent straining efforts set in, expelling the black, ill-smelling, 
gangrenous mass, either in its entirety or in patches and shreds, 
together with a large quantity of dark, offensive, feculent mat- 
ter. The child then falls into a deep sleep, and awakes much 
refreshed. Thirst diminishes ; the appetite returns ; the parox- 
ysms of pain cease ; the face expresses ease and comfort, and 
the path to health is rapidly traversed. 



350 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

When death occurs, it is usually due to asthenia, and may, 
as in infants, be preceded by convulsions. General peritonitis 
is very uncommon. 

In addition to the form of intussusception just described, 
and which may be termed acute, a variety having a much 
more prolonged course is sometimes encountered. 

Chronic intussusception may occur at any age, and may exist 
for weeks, or even months, without producing severe illness. 
It originates most frequently in ileo-csecal intussusceptions, 
and depends upon the inflammatory union of the outer and 
middle layers, and the restoration of the permeability of the 
inner tube by the complete disappearance of the swelling. 
The patient wastes, has periodical attacks of colicky pain, con- 
stipation, and vomiting, and occasionally passes a little blood. 
Palpation reveals a tumor that alters its position, shape, and 
density from time to time, and, on account of hypertrophy of 
the muscular coat above the partial obstruction, the knuckles 
of the intestine show distinctly through the emaciated abdom- 
inal wall. 

Such cases may end in recovery, by separation ; or in death, 
by perforative peritonitis ; or by steadily increasing marasmus 
with chronic diarrhoea. 

Diagnosis. — Intussusception may be strongly suspected 
when a child in good health, or previously affected with sim- 
ple diarrhoea, is suddenly seized with violent, paroxysmal 
abdominal pain and vomiting, quickly followed by straining 
efforts, resulting in the evacuation of mucus and blood, and 
by intense prostration. 

The suspicion will be reduced to a certainty if, at the same 
time, it be possible to detect a sausage-shaped tumor on 
the left side of the belly, or to touch the lower end of the 
inverted intestine upon rectal exploration. It is necessary 
to remember, however, that often, at the commencement of 
the attack, there is a single loose feculent stool, and also that, 



AFFECTIONS OF THE STOMACH AND INTESTINES. 35 I 

in older children, bloody, mucous discharges may be entirely 
absent. 

The diseases with which intussusception is most likely to 
be confounded are simple colic, perforative peritonitis, dysen- 
tery, and faecal accumulation within the bowel. 

In simple colic, the pain, though often severe, is never dis- 
tinctly paroxysmal. It is attended by suppression of urine, 
is relieved by the discharge of flatus per anum, and is followed 
by copious urination. During the attacks the skin may be 
hot, and the belly is usually hard and tense. There is no 
vomiting, tenesmus, or discharge of bloody mucus. The 
misfortune of confounding intussusception with colic can 
hardly be overestimated ; for a laxative, as castor oil, while 
relieving the latter by clearing out the intestinal canal, cannot 
fail to aggravate the former by increasing the force of the 
peristaltic contractions. 

In perforative peritonitis there is pyrexia from the begin- 
ning, the abdomen is distended and tense, and pressure in the 
right iliac region — since the seat of perforation is usually the 
vermiform appendix — produces pain. On the other hand, 
tenesmus and the evacuation of blood and mucus from the 
rectum are never observed, neither is it possible to detect a 
tumor by abdominal palpation, nor the lower end of an intus- 
susception by rectal exploration. 

Dysentery presents, in the character of the dejections and 
the severe pain and tenesmus, features similar to intussuscep- 
tion, but it lacks the sudden onset, the obstinate vomiting, and 
the abdominal tumor. The two diseases differ, too, in their 
course. 

A faecal accumulation, as it produces actual occlusion of the 
intestine, has many symptoms similar to invagination. Thus, 
there is vomiting, colicky pain, tenesmus, constipation, and a 
tumor. The former accident, however, is preceded, for some 
time, by the passage of hard and scanty stools ; while the 



352 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

attendant vomiting is less obstinate ; there are no bloody- 
evacuations ; and the tumor is more superficial, more fixed, 
and of such consistence that it can be indented by moderately 
firm pressure with the fingers. A purgative enema, also, rap- 
idly leads to the expulsion of the impacted mass and relieves 
the symptoms. 

Prognosis. — Every case of intussusception affords an out- 
look that is grave in the extreme, though the' danger to life 
depends directly upon two factors : namely, the age of the 
patient attacked, and the acuteness and consequent severity 
of the symptoms. In children under one year, death almost 
invariably results. With those who are older, the constitu- 
tional resistance being greater, sloughing of the intussuscep- 
tion is more apt to take place and recovery follow ; but the 
rarity of this fortunate termination at any time of life has 
already been alluded to. 

Treatment. — In no other disease does the prospect of suc- 
cess rest so much upon an early diagnosis and appropriate 
management. 

The indication to be met is the total arrest of all action of 
the muscular fibres of the intestine. To accomplish this end, 
the patient must be kept in a state of absolute repose ; must 
be made to take enough opium to relieve pain and check in- 
testinal peristalsis, and must be carefully and properly fed. 
Absolutely no purgative measure should be instituted. 

Opium may be employed alone or in combination with bel- 
ladonna, and may be administered by the mouth, by the rec- 
tum, or, in children over a year old, by hypodermic injection. 
A combination of the two drugs and their administration by 
the rectum is to be preferred in ordinary cases. For a child 
of one year the following suppository may be ordered : 

R . Ext. opii, gr. iss 

Ext. belladonnae, gr. ss 

01. theobromae, 3 ij. 

M. et ft. supposit. No. xij. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 



J D J 



In the beginning, one of these suppositories can be intro- 
duced every two hours ; but the interval must be lessened or 
the dose increased to the point necessary to relieve pain and 
tenesmus. 

When the mouth is selected as the channel of exhibition, 
the opium and belladonna may be prescribed in a mixture, as : 

S<. . Tr. opii deod., fgj 

Tr. belladonna?, *o 5S 

Aquas anisi, q. s. ad i^iij. M. 

SiG. — One teaspoonful every two hours (or p. r. n.) for a child of one year 
of age. 

When the hypodermic method is selected, it is still best to 
combine the two drugs, thus : 

R . Morphince sulphatis, gr. | 

Atropinte sulphatis, § r - To 

Aquae destillat., . f^j. M. 

SiG. — Inject ten minims p. r. n. for a child of six years. 

The application of anodynes to the surface of the abdomen 
has certainly some power in relieving pain, and should, con- 
sequently, not be neglected. For this purpose a piece of soft 
flannel, large enough when doubled to cover the whole belly, 
should be dipped in hot water, wrung moderately dry, 
sprinkled with a teaspoonful of laudanum, laid over the sur- 
face and covered with oiled silk. 

As to food, only so much as is absolute!}- required to sus- 
tain life should be allowed. For the first twenty-four or forty- 
eight hours, especially if there be vomiting, food must be 
altogether withheld, and a teaspoonful of barley water or a 
small bit of ice given every fifteen minutes to allay the thirst. 
Later, milk and barley water for infants, and milk, beef juice 
or broths, and strong beef essence for older children, are ad- 
missible ; but always in minimum quantities and at intervals 
of two or three hours. Thus, for a child of one year, half an 
ounce of milk and barley water, in equal parts, every two 
30 



354 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

hours, will be quite enough ; while at the age of six years 
two ounces of milk, one ounce of broth or beef essence, or 
two nuidrachms of beef juice every three hours will suffice. 
It is well to peptonize the food, as in this way it is prepared 
for assimilation, and little residue is left in the intestinal canal. 
Everything must be taken cold. 

When the strength begins to fail, brandy must be adminis- 
tered. The following mixture is a good food and stimulant : 

Brandy, ...,..., 4 fruidounces 

Cinnamon water, 4 fluidounces 

The yolks of two eggs, 

White sugar, % ounce. 

Rub the yolks and sugar together, then add the cinnamon water and spirit. 
Dose. — A dessertspoonful to two tablespoonfuls every two hours, according 
to the age. 

Should the patient be seen before the fourth day of the 
attack, in addition to the above measures of treatment, efforts 
should be made to reduce the involution mechanically. Me- 
chanical interference can be successful only before inflamma- 
tory adhesions have formed, and is contraindicated when 
there is tenderness over the seat of lesion. There are three 
possible ways of accomplishing reduction : viz., by taxis, by 
forced injection of water, and by insufflation of air. To 
perform either of these successfully the patient, unless an 
infant under one year, must be previously put thoroughly 
under the anaesthetic influence of ether. 

Taxis consists in kneading and otherwise manipulating the 
abdomen with the warmed and oiled hand ; it is usually 
employed in conjunction with one of the other methods. 

If forced enemata be resorted to, the child is placed upon 
his back in bed, with the pelvis elevated, so that the trunk is 
inclined at an angle of 45 degrees. Then, with a Davidson's 
or fountain syringe, the physician himself must inject, care- 
fully and slowly through a catheter, as much normal saline 



AFFECTIONS OF THE STOMACH AND INTESTINES. 355 

solution, at a temperature of 105 °, as the capacity of the 
intestine will permit ; reflux being prevented by firm com- 
pression of the buttocks. While this is being done, the 
abdomen must be kneaded in such a manner as to force the 
water upward along the bowel in the direction of the invagina- 
tion. At times the obstruction can be felt to give way ; but 
the best proofs of this fortunate occurrence are the subsidence 
of the more urgent symptoms and the onset of sound sleep. 
Soon, too, there is a discharge of bloody mucus from the 
rectum, and then a free, offensive, semi-fluid faecal evacuation. 

Insufflation of air is suited to those cases in which, the 
intussusception having descended into the rectum, little or no 
water can be injected or retained. The apparatus for this 
purpose consists of a bellows, having its nozle attached, by 
means of a piece of flexible rubber tubing, to a caoutchouc 
tube about a foot in length ; the latter is inserted into the 
rectum, care being taken to prevent escape backward by the 
means employed in injecting liquid. The air should be 
pumped in slowly and gently, and during its introduction 
taxis is practised in the same manner as in the forced injection 
of water. After reduction, the patient must be kept in bed 
and under the influence of opium for several days ; the diet 
must be very low, and cathartics must be avoided for three or 
four days. 

Should the above measures of reduction fail, or should the 
case be seen for the first time after the third or fourth day, 
the question may arise as to the propriety of laying the 
abdomen open and reducing the intussusception by direct 
traction. For the details of the operation of laparotomy, the 
reader must be referred to works on surgery. Briefly stated, 
it consists in making an incision in the median line of the 
abdominal wall, opening the peritoneum, finding the intussus- 
ception, and working it back at the neck in the same manner 
as a hernia is reduced. The result of operation depends 



356 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

greatly upon the stage of the disease at which it is performed. 
If undertaken early, before adhesions have formed, a fair 
proportion of cases are successful. If so late that the 
invagination cannot be reduced by traction after opening the 
abdomen, or after gangrene has set in, death is the almost 
invariable termination. Surgical interference, then, should not 
be delayed after a brief but thorough trial of the ordinary 
methods of reduction. 

When spontaneous separation and discharge of the invagi- 
nated segment of the intestine takes place, it is necessary to 
exert the utmost care lest the new-formed adhesions be 
broken down. The patient must lead a passive life ; the food 
must be readily digestible and restricted in quantity, and all 
farinaceous and fermentable articles are to be excluded from 
the dietary. 

In chronic intussusception great reliance can be placed 
upon the free administration of opium and belladonna, with 
forced enemata, or, in proper cases, insufflation of air ; and as 
this condition generally occurs in late childhood, laparotomy, 
when other measures fail, is more frequently successful. 

INTESTINAL WORMS. 

The common parasitic worms that find their habitat in the 
human intestines may be divided into two classes, each 
including several varieties, namely : 



Nematodes. 



Cestodes. 



r Oxyuris vermicularis. 
X Ascaris lumbricoides. 



Tricocephahis dispar. 

' Tcenia saginata, or mediocanellata. 
Tcenia solium. 
Bothriocephalic lattis. 
Tcenia cucumerina. 
T&nia nana. 



Of these, the oxyuris vermicularis (small thread worm) and 



AFFECTIONS OF THE STOMACH AND INTESTINES. 357 

the ascaris lumbricoides (long, round worm) are most fre- 
quently found in children. The taenia, or tape-worm, is un- 
common before the age of six or seven years. 

DESCRIPTION AND MODE OF ENTERING THE BODY. 

Oxyuris Vermicularis. — These worms are silvery-white 
in color and of small size ; the males being one-sixth of an 
inch, the females one-half an inch long. To the unaided eye 
they present the appearance of small, white threads. They 
inhabit the caecum and whole length of the colon, but are 
most abundant in the sigmoid flexure and rectum, where they 
derive nourishment from the faeces, and where, alone, they 
give rise to symptoms or evidences of their presence. 

Oxyures enter the body by direct passage of the ova into 
the mouth. They are introduced clinging to fruit and various 
articles of food, or are conveyed to the lips by the hands of 
the child previously used to relieve itching occasioned by the 
presence of the parasites in the neighborhood of the anus. 
Having entered the stomach, the embryos are liberated by 
the action of the gastric juice and pass into the small intes- 
tine, which they descend with the food, developing so rapidly 
that they become sexually mature by 
the time they reach the caecum. 

The eggs, as seen by the microscope, 
are ^-q of an inch in length, ovoid and 

, • 1 ^ri 1 1 • Fig. 10. — Egg of Oxyuris 

unsymmetncal. lney are produced in vermicularis. 

great numbers, each female giving birth 

to several broods, numbering from ten to twelve thousand, 
and they are extremely tenacious of vitality. 

Ascaris Lumbricoides. — This parasite has a certain su- 
perficial resemblance to the common earth-worm. It is cylin- 
drical, tapering at both extremities, is reddish or brownish in 
color, has a body marked with fine transverse rings, and 
possesses a peculiar, disagreeable odor independent of the 





•358 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

substance in which it lives. The head of the worm presents 
three prominent labial papillae surrounding the mouth, and the 
tail is conical. The male is from three to six inches in length 
and one-eighth of an inch in thickness, with an incurved tail 
and a penis consisting of a pair of slender, clavate, chitinous 
spicules, the ends of which protrude from a cloacal aperture 
at the root of the tail. The female measures from six to 
fourteen inches in length and one-fourth of an inch in thick- 
ness. The genital aperture is situated on the ventral surface, 

near the anterior third of the body ; 
the ovarian tubes may be observed 
as long, tortuous canals, and the 
uterine tubes as short, straight 
canals ; the latter contain many 
millions of ova. The ripe ova are 

Fig. 11. — Egg of Ascaris .... - . . . 

lumbricoides. laid in the intestine, and are ex- 

pelled, with the stools, in great 
numbers, sometimes even in large masses. The eggs are^-J-g- 
of an inch in diameter, and are oval, with a thick, elastic, 
brownish, double shell and nodulated surface. After expul- 
sion from the rectum, they are very tenacious of life, remain- 
ing in a condition capable of development for several years. 
This is particularly the case when they find their way into 
water or moist earth. Here the embryos slowly develop. 

It is not positively known in what way children become in- 
fected with the parasite, but impure water is, without doubt, 
the medium. Recent experiments on both animals and men 
have demonstrated that infection cannot be directly produced 
by taking the recently laid, ripe ova into the stomach. It is 
probable, therefore, that the ova .passed by an infected subject, 
after entering — through drainage or otherwise — moist soil or 
running water, and undergoing partial development, are eaten 
by some common, but unknown, minute aquatic animal. 
Within the bodies of these they are still further developed, so 



AFFECTIONS OF THE STOMACH AND INTESTINES. 359 

that, when the animalculi are ingested with impure drinking- 
water, and the embryos liberated by the action of the diges- 
tive solvents, the latter are in a position rapidly to assume 
their mature characters. Epstein denies that an intermediate 
host is necessary, having found by experiment that five weeks' 
cultivation of eggs taken from evacuated faeces is sufficient, 
under proper conditions of light and air, to develop the em- 
bryos, and that in three months after these are fed to children 
ova appear in the stools and worms are expelled after the 
administration of an anthelmintic. 

Lumbrici inhabit the small intestine principally, though 
they frequently migrate. Their number in a single individual 
may vary from two to several hundred. 

Tricocephalus Dispar. — The whip-worm, as this parasite 
is sometimes called, is yellowish-white 
in color, with the anterior half, or more, 
of the bod\' attenuated in a hair-like 
filament. The male is about one inch 

Fig. 12. — Egg of Trico- 

and a half in length, has the thick portion cephalus dispar. 

of the body enrolled, and a blunt tail. 

The female is two inches longf, with a conical tail. The eo-a-s 
of this worm are laid in the intestine and voided with the 
faeces ; nothing is known of their subsequent history, or of 
the method in which the human being is infected. 

Whip-worms inhabit the lower end of the ileum, the caecum, 
and the vermiform appendix, and feed on the intestinal con- 
tents. They are met with in small colonies, varying in num- 
ber from two to twelve. Their occurrence is considered to 
be exceptional in this country, but this may-be explained in 
two ways : first, as they are rarely voided with the faeces, like 
other worms, they escape ordinary observation ; and, second, 
as their presence gives rise to no symptoms during life, few 
think of looking for them on the post-mortem table. 

Taeniae infest children over the age of six years with almost 




360 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

the same frequency as adults. Of the several varieties, the 
tcenia saginata, beef tape-worm, and tarda solium, pork tape- 
worm, are the most common ; while of these two, the former 
is met with in by far the greater number of cases. 

Taenia saginata is a soft, yellowish-white, band-like 
worm, varying in length from six to twenty or more feet. 
The head has about the bulk of a yellow mustard-seed, is 
rounded quadrate, and provided with four hemispherical 
suckers. Between the head and body is a short, unseg- 
mented, flattened neck, narrowest at its upper extremity and 
gradually broadening as it merges into the body. The latter 
is distinctly segmented. The first segments are several times 
wider than long, but become successively larger until the 
length exceeds the breadth two or three times ; their number 
may reach twelve hundred, and the largest 

©measure from one-fourth to one-third of an 
inch in width, and a quarter to a full inch 
in length. The parasite is usually solitary. 
It inhabits the small intestine, in which po- 

Fig. 13.- Egg of , " . 

taenia saginata. sition the segments, as they ripen, are spon- 
taneously detached, some having already 
expelled their burden of eggs (often numbering 35,000), 
others still laden. Both eggs and liberated segments • then 
become mixed with the intestinal contents, pass downward 
into the colon, and are finally expelled with the faeces. The 
mature ova are brown, oval in shape, and of minute size ; 
they have a thick inner shell, and an outer longitudinally 
striated envelope. Each ovum contains an embryo — a spheri- 
cal or oval body — having at one pole three pairs of diver- 
gent, boring spiculae. 

In rural districts, it is a very common habit, with both 
adults and children, to stool in a fence corner, or other more 
or less secluded spot, at any time there is a call for evacuat- 
ing the bowels. Should ova-laden tape-worm segments or 



AFFECTIONS OF THE STOMACH AND INTESTINES. 36 1 

liberated eggs be contained in the faeces so carelessly depos- 
ited, these are apt to be swallowed by cattle grazing in the 
neighborhood. Having once entered the stomach, the em- 
bryos, liberated from the eggs by the action of the digestive 
solvents, attach themselves to the mucous membrane of the 
viscus, perforate it by means of their powerful boring appa- 
ratus, and, either directly or through the medium of the 
blood current, migrate into the tissues of the body, usually 
the muscles or liver. After attaining their destination, they 
become fixed and slowly undergo development, dropping the 
spiculae and being transferred into the larval form or scolex. 
The scolex consists of a head like that of the mature worm, 
with a neck terminating in a capacious cyst, within which the 
head and neck are inverted. In this form each parasite is 
surrounded by a sack of connective tissue ; the new forma- 
tion, depending upon the presence of the larva, acting like an 
embedded foreign body. The flesh, liver, and other organs 
of cattle so infected are said to be " measly. " Xow should 
measly beef be taken into the stomach insufficiently cooked, 
or should it be administered raw, — a frequent practice in the 
treatment of certain intestinal diseases, — the parasite, during 
the process of digestion, is liberated from the investing con- 
nective-tissue envelope, everts its head from the containing 
sack, attaches itself to the mucous membrane of the small 
intestine, feeds upon the intestinal contents, and, growing 
from its caudal extremity, rapidly develops into a mature 
tape-worm. The time required for development has been 
proved by experiment to be less than two months, and the 
natural duration of life is very protracted. 

Taenia Solium. — This species of tape-worm enters the 
human body through the medium of measly pork. The 
methods of propagation and development are identical with 
those of the taenia saginata. In general appearance, also, the 
two worms are very similar. The pork tape-worm, however, 



362 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

is white in color and broader and shorter, the usual length 
being between five and ten feet. The head, which presents 
the most prominent distinguishing features, is about the size 
of that of an ordinary pin ; it is spheroidal in shape, is sur- 
mounted by a blunt papilla, encircled by a double row of hooks, 
and, at the same time, has the four hemispherical suckers to 
be noticed in the beef tape-worm. The ova are somewhat 
smaller, but otherwise identical ; the scolices, long known as 
Cysticercus celluloses, likewise possess the double row of hooks 
to the head, and in this way may be distinguished from the 
larvae of the other variety of taenia. The period occupied in 
development is about three months ; the length of life prob- 
ably twelve years or more. 

As in the United States pork is but little used as food in com- 
parison with beef, and when used is thoroughly cooked, the 
difference in the frequency of occurrence of the two species of 
worms can be readily explained. In regard to this point, Prof. 
Leidy states : " Since the writer distinctly recognized the beef 
tape-worm, within the last twenty years, all the specimens of 
taeniae, from people of Philadelphia and its vicinity, that have 
been submitted to him for examination — perhaps in all about 
fifty — have appeared to belong solely to taenia saginata. The 
prevalence of this species with us is no doubt due to the 
common custom of eating underdone or too rare beef, while 
the pork tape-worm is comparatively rare, as with us pork is 
only used in a well-cooked condition." 

Bothriocephalus latus is very uncommon except in some 
portions of Europe. The larvae have their habitat in certain 
fish, and through this form of food are introduced into the 
human body. 

Taenia Cucumerina. — The larvae of this worm develop in 
a parasite living upon the skin of dogs and cats. Children 
who make companions of these animals carry the larvae to 
their mouths upon their hands ; even very young subjects may 



AFFECTIONS OF THE STOMACH AND INTESTINES. 363 

be infected in this way ; in fact, most of the tape-worms found 
in infants belong to this variety. The worm is much smaller 
than either the T. saginata or T. solium, the full length being 
from six to twelve inches ; it is also much less frequently 
encountered. 

Taenia nana is, as yet, very rarely met with in this 
country, but it is common in Italy, and with increasing immi- 
gration its more frequent occurrence may be anticipated. 
This variety of worm especially affects children, and may 
exist in great numbers in one individual. It is very small, 
measuring from four to six lines in length ; the head is armed 
with four suckers and a rostellum of hooks, capable of being 
protruded or withdrawn. 

Symptoms. — These may be divided into two classes : 
general and special. 

The general symptoms are those always present, irrespec- 
tive of the particular species of worm infecting the patient. 
They depend not so much upon the mere presence of the 
parasite, as upon the peculiar condition of the mucous mem- 
brane of the alimentary canal which accompanies and is, 
perhaps, essential to their development and existence. This 
condition is one of catarrh, with an excessive production of 
mucus. 

The patient wastes, and the face is pale or leaden in hue, 
dark circles surround the orbits, the eyeballs are sunken, the 
pupils dilated, and the upper lip swollen. The skin generally 
is muddy, covered with dry, epidermic scales, and devoid of 
natural softness and elasticity. 

The lips and mucous membrane of the mouth are pale, the 
breath is offensive, and the tongue is flabby, with the edges 
indented by the teeth and the dorsum covered with a thin, 
slimy coating. There is often moderate hypertrophy of the 
tonsils and swelling of the lymphatic glands at the angles of 
the jaw. The appetite is capricious, sometimes almost absent, 



364 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

and at others insatiable. Nausea, acid eructations, and vomit- 
ing are common. Constipation is the usual state of the 
bowels ; occasionally there is tenesmus, with constant unpro- 
ductive efforts at defecation, and there is liability to attacks of 
diarrhoea, attended with great straining and the passage of 
black, slimy, ill-smelling motions. Free mucus may be dis- 
charged from the rectum, and, in girls, from the vagina. 
The abdomen is always distended, feels hard on palpation, 
and to percussion yields a tympanitic note. Constant com- 
plaints are made of pain in the belly, especially in the 
neighborhood of the umbilicus. Its character varies, being 
in some cases tearing or cutting ; in others, simply an uneasy, 
creeping sensation, and in others still, a sensation of coldness. 

The urine is frequently voided with pain and difficulty, and 
may have a turbid, milky appearance. 

The pulse is weak, altered in frequency, and occasionally 
irregular ; a harassing, paroxysmal cough may be present, 
and not uncommonly there is sighing, sobbing, and hiccough. 

The child's temper is altered ; he becomes irritable or 
sullen ; his sleep is broken by bad dreams or night terrors ; 
and there are many and very diverse nervous manifestations, 
such as annoying itching of the nose, temporary delirium or 
stupor, sudden blindness, loss of voice, squinting, fixation of 
the eyeballs, vertigo, and general convulsions. 

These features, of course, are not equally marked in all 
cases, their degree depending upon the grade of intestinal 
catarrh. 

Special symptoms — those due directly to the presence of 
the worms — differ according to the species. 

The oxyures occasion violent itching at the anus, especially 
at night, when they prevent sleep and lead to troublesome 
scratching. The irritation, transmitted to the genitalia, com- 
bined with the constant application of the hands to these parts, 
produces erections in the male, and may induce the. habit of 



AFFECTIONS OF THE STOMACH AND INTESTINES. 365 

masturbation in both sexes. Two conditions of the bowels 
are observed ; either forcible but ineffectual straining, often 
attended by prolapsus ani, or diarrhoea. Finally, the oxyures 
may, on inspection, be discovered moving about in the 
radiating folds of the anus. 

Occasionally these parasites migrate into the vagina, uterus, 
urethra, oesophagus, and stomach. When they occupy the 
vagina, they give rise to leucorrhcea. 

Lumbrici occasion more or less pain in the umbilical region ; 
also headache, vertigo, convulsions, epileptiform attacks, 
transient paralysis, and even chorea. The irritation of their 
presence may cause chronic diarrhoea, with scanty, offensive, 
thin, mud-colored stools, voided with much straining, and 
most numerous during the night. They often migrate into 
the stomach, whence they are quickly expelled by vomiting. 
Less frequently they pass into the common bile-duct and 
gall-bladder ; also the nose, larynx, trachea, larger bronchi, 
vagina, urethra, and bladder ; in each position giving rise to 
symptoms of irritation. They have been found, too, in 
abscesses communicating with the intestine, having escaped 
by entering a pre-existing fistulous opening, or, perhaps, in 
some instances, by directly perforating the gut. These 
abscesses usually occupy the abdominal wall in the umbilical 
or inguinal regions, or are seated in the substance of the liver. 

As already stated, the tricocephalus dispar causes no 
special symptoms. 

Taeniae are attended by sensations of weight and gnawing 
in the abdomen ; occasional attacks of colic, and distention, 
particularly of the umbilical region. With a huge appetite, 
there is progressive emaciation and general lassitude. A 
persistent headache is sometimes a feature, and there may be 
annoying cramps in the muscles of the legs and arms. 

Diagnosis. — While the occurrence of the symptoms 
detailed strongly indicates the presence of worms, the only 



366 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

positive proof of their existence is the discovery of the 
parasites themselves or of their eggs in the stools ; their 
appearance, as in the case of oxyures, at the margin of the 
anus ; and their expulsion, as in the case of lumbrici, from 
the stomach in the act of vomiting. Therefore a purgative, 
by emptying the intestinal tract and expelling some of the 
parasites, is the crucial test. 

In some cases the symptoms are severe enough to suggest 
tuberculosis or tuberculous meningitis ; though a mistake may 
be readily avoided by bearing in mind this possibility and 
applying the test. 

Prognosis. — Intestinal worms rarely cause death. When 
a fatal termination does occur, it results from convulsions ; 
from the consequences of the migration of the parasite into 
the bile duct and air passages, or from some secondary affec- 
tion ; proving dangerous because the strength of the frame 
attacked has been sapped by its guests. 

Treatment. — The diagnosis having been established, either 
by the spontaneous appearance of the worms or by their dis- 
covery after the administration of a dose of calomel or calo- 
mel and rhubarb, remedial measures must be directed to the 
accomplishment of two objects : First, the expulsion of the 
worms ; and second, the removal of the alkaline mucus — the 
essential nidus — and the restoration of the alimentary canal 
to its normal condition. 

First : For expelling the parasites, the anthelmintic to be 
chosen depends upon the infecting species. 

Oxyures, as they inhabit the rectum, are within the reach of 
enemata, and are best treated by this means. The object being 
to kill the worm, it is essential thoroughly to empty the lower 
bowel by an enema of warm water, immediately before in- 
jecting the parasiticide, so that the latter may come in con- 
tact with the mucous membrane, upon which the great mass 
of the worms lies. One or two medicated injections can be 



AFFECTIONS OF THE STOMACH AND INTESTINES. 367 

administered daily ; they act best when cold, and their bulk 
should not be so large as to distend the gut and lead to a 
quick return ; from one to two fluidounces is the proper 
quantity for a child of two years.* Liquor calcis ; common 
salt and water, in the proportion of one teaspoonful to a pint ; 
a solution of castile soap, thirty grains to a pint of water, or 
one of sulphuret of potassium, twelve grains to a pint ; oil 
of turpentine in milk ; half a teaspoonful to four fluidounces 
of pure olive oil ; and lard beaten up with water until it be- 
comes liquid, all constitute good injections, the last two hav- 
ing the property of quickly relieving itching, in addition to 
their parasiticide action. In my experience, however, the 
injection of an infusion of quassia has been most uniformly 
successful. The infusion is best prepared in the nursery, thus : 

r£ . Quassias (rasped), sjij. 

SiG. — Place in a porcelain vessel and pour on a pint of boiling water, macer- 
ate for two hours, then strain and inject two fluidounces once or twice 
daily. 

With children past the second year the proportion of quas- 
sia may be gradually increased to one ounce, at the age of 
seven. 

While employing enemata it is well to aid their action, 
and relieve itching at the anus, by anointing the parts with 
some mild mercurial ointment, and at the same time pushing 
a little into the rectum. A good preparation of this kind is : 

R . Hydrargyri chloridi mitis, gr. lxxx 

Unguenti petrolei, . . . ^j. M. 

SiG. — Apply morning and evening. 

When there is intense rectal irritation, an injection of 
laudanum and starch water (gtt. iij to foj) and cold com- 
presses applied to the fundament give great comfort. 

* All of the succeeding directions for treatment are adapted to children of 
this age. 



368 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Diarrhoea and tenesmus are to be overcome by the admin- 
istration of a teaspoonful of castor oil, with five drops of 
paregoric, once, twice, or three times daily, according to cir- 
cumstances. Should there be constipation, one teaspoonful 
of Husband's magnesia, or the appropriate dose of some 
other saline, must be given every morning until the symptoms 
disappear. Besides keeping the bowels regular, it is well to 
secure several free watery evacuations, at intervals of three 
days, for the purpose of dislodging any oxyures that may be 
inhabiting the upper part of the large intestine, and of clear- 
ing away accumulations of mucus ; to accomplish this, saline 
cathartics are to be selected. 

Against lumbricoides several drugs are useful. Of these, 
santonin, spigelia, and chenopodium are the most efficient. 
To insure the greatest success, the patient for whom any of 
these medicines is ordered must be placed on a restricted 
liquid diet, that the alimentary canal may be as empty as 
possible ; and during their administration the bowels must be 
kept active by cathartics, that the dead worms and the ova 
may be swept away. Broken doses of the purgative chosen 
can be combined with the anthelmintic, or an occasional full 
dose may be given during the course of the treatment. 

Santonin is almost tasteless, and when combined with sugar 
is readily taken by children ; it may be prescribed in the 
following ways : 

R . Santonini, gr. vj 

Sacchari, gr. xxx. 

M. et ft. chart. No. xij. 
SiG. — One powder morning and evening, each second dose to be followed by 
two teaspoonfuls of castor oil or a purgative dose (gr. j) of calomel. 

Or— 

& . Santonini, . . gr. vj 

Hydrarg. chlorid. mit, gr. vj 

Sacchari, gr. xxiv. 

M. et ft. chart. No. xij. 

SiG. — One powder morning and evening. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 369 

Santonin sometimes produces xanthopsia, or "yellow-see- 
ing" ; this is of no importance, and quickly disappears after 
the drug is discontinued. It is best, however, to advise the 
mother or nurse of the possibility of this occurrence. Occa- 
sionally, too, it increases the flow of urine and gives the fluid 
a reddish color. 

Spigelia is a very useful remedy, though as it simply nar- 
cotizes the worm, it must always be administered in associa- 
tion with a purge. The officinal preparation, extractum 
spigelian et sennae fluidum, is as good a combination as can be 
employed ; it may be given in doses of one teaspoonful three 
times daily. If it be desired to make success doubly sure, it 
is well to add santonin : 

1J. Santonini, . gr. iv 

Ext. spigeliie et sennae fid., f 3 iss 

Syrupi, f % ss 

Elix. simplicis, q. s. ad f^iij- M. 

SiG. — Two teaspoonfuls three times daily. 

Chenopodium is a very safe, non-irritant anthelmintic, being 
especially -indicated when the evacuations are increased in 
number, are liquid, and contain mucus or blood. The vola- 
tile oil may be administered dropped upon a lump of white 
sugar, in doses of five drops three times daily. A purgative 
is then necessary, every twenty -four or forty-eight hours, or, 
for convenience, both remedies may be combined in a mix- 
ture : 

R. Olei chenopodii, f 3 ij 

Olei ricini, f ^ iss 

Olei cinnamomi, w\\ 

Syr. acacise, q. s. adf^iij. M. 

SiG. — One teaspoonful three times daily. 

Should there be reason to suspect ulceration of the bowel, 
five minims of oil of turpentine added to each dose of this 
31 



37° DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

formula will both improve the condition of the mucous mem- 
brane and increase the specific action. 

The only disadvantage possessed by oil of chenopodium is 
that it is not so acceptable to the taste or stomach as either 
santonin or the liquid extract of spigelia and senna. 

Whip-worms, when detected, can be removed by the same 
means as lumbricoides. 

Taeniae are the most difficult of the intestinal parasites to 
eradicate ; evacuations of many feet of segments are easily 
brought about, but reproduction steadily continues until the 
head is finally expelled. This portion is obstinate in its ad- 
herence to the intestinal mucous membrane and being minute 
in size, is easily shielded from the action of the parasiticide 
by the tenacious mucus which is always secreted in excess 
when a tape-worm is present. 

It is essential, therefore, to diminish, or, if possible, entirely 
remove, this secretion, before commencing the actual treat- 
ment. For one week the child * must take the following pre- 
scription : 

1£ . Ammonii chloridi, 3 ij 

Ext. sennae fid., f3 v j 

Inf. gentianae comp. , q. s. ad f^iij. M. 

SlG. — One teaspoonful before each meal. 

At the same time the diet must be restricted, and non- 
farinaceous in character ; for instance : 

Breakfast at 8 a. m. — A tumblerful and a half (12 oz.) of 
milk, with two slices of gluten bread. f 

Luncheon at 12 m. — A teacupful (4 oz.) of milk. 

Dinner at 2.30 p. m. — A bowl (8 to 12 oz.) of beef-, mut- 
ton-, or chicken-broth ; two slices of gluten bread. 

Supper at 7 p. m. — Same as breakfast. 

*This and the succeeding formulae are adapted to children of six years. 
(Gluten flour can be obtained in any of the larger cities, and is made into 
bread in the same manner as wheat flour. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 37 1 

For drink at dinner or between meals only pure filtered 
water in small quantities. 

At the end of the week's preparation one of the anthel- 
mintics particularly adapted to this species of worm may be 
ordered. 

For a long time the bark of the pomegranate root has been 
known as a remedy for " taenia," or tape-worm ; but the diffi- 
culty of procuring it fresh, the short time it keeps good, and 
its unpleasant taste have greatly limited its use. Besides, it 
has been ascertained that its action is variable, according to 
the season of collecting, the age and vigor of the tree, etc. 
It is this uncertainty that compelled Professor Laboulbene, 
Member of the Academy of Medicine, who has made the 
cure of taenia a specialty, and who considers the bark of 
pomegranate root the best and most efficacious remedy, to 
say: " I wish that some one would discover and separate 
from the tseniacide plants a sure alkaloid, always identical, 
and that would act with certainty, which is something we 
cannot obtain from pomegranate bark, or from old koosso, 
which is nearly inert." 

M. Tanret has found this alkaloid, and for his discovery 
has been awarded the " Barbier Prize" by the Academy ot 
Sciences. He calls it pelletierine, in honor of the illustrious 
chemist, who, with Caventou, has made numerous discoveries 
in organic chemistry of great benefit to humanity. 

Tanret's pelletierine has given the most satisfactory results 
in the hospitals where it has been tried ; for instance, at the 
Marine Hospitals of Toulon, St. Mandrier, etc., and in Paris, 
St. Antoine, La Charite, Necker and Beaujon, etc. Dujardin- 
Beaumetz, Member of the Academy of Medicine, declared 
to the Society of Therapeutics that he was successful in 
thirty-two cases out of thirty-three treated with pelletierine, 
and Professor Laboulbene was successful in every case in 
which he used it, fourteen in all. My own experience with 



372 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

this drug has been most successful, and I have relied upon it 
exclusively for a number of years past. 

Pelletierine is dispensed in bottles containing the proper 
dose for an adult, and one dose is usually sufficient. For 
children from nine to twelve years, half the adult dose is 
sufficient. In administering the drug, certain preliminaries 
are indispensable to insure success. 

When pieces of tape-worm are or have been ejected within 
a short time after some other remedy has been taken without 
expelling the head, pelletierine should not be taken until some 
pieces of the worm are again noticed. 

In the evening the patient must be given a large laxative 
injection, and be placed on milk diet. The next morning 
mix half, or less, according to age, of the contents of a bottle 
with a half-glass of sweetened water, and administer at one 
dose ; three-quarters of an hour to an hour after, give from 
two to four fluidrachms of compound tincture of jalap, 
mixed with two fluidounces of sweetened water. Compound 
tincture of jalap is the best purgative, but it can be substi- 
tuted by any other quickly acting cathartic. 

If the bowels are not relieved in a few hours after giving 
the purgative, then administer either another purgative or an 
injection of normal saline solution. A few minutes after tak- 
ing pelletierine there will be a sensation of giddiness, and the 
entire tape-worm will be passed from two to four hours later. 

Oleoresin of male fern — oleoresina filicis — is frequently 
employed and is quite efficient ; it should be given in one or 
two drachm doses, either floating upon a little peppermint 
w T ater (f§ss) or in a mixture, such as : 

Ht . Oleoresinse filicis, f^ij-iv 

Syr. acaciae, f^ij 

Aq. cinnamomi, q. s. adf^j. M. 

Sig. — Tablespoonful for a dose. 

The plan of administration has much influence on the 



AFFECTIONS OF THE STOMACH AND INTESTINES. 373 

issue. For the best result, the patient, unless much debili- 
tated, must, upon the day on which the treatment is instituted, 
begin a fast after his dinner ; in the evening two fluidrachms 
of castor oil should be given ; next morning, after the bowels 
have been thoroughly evacuated, a dose of fern ; and three 
hours later, a second dose of castor oil. A few hours subse- 
quently the worm will probably be expelled. During the 
interval, occasional sips of water may be allowed to relieve 
thirst. The nauseating taste of the oleoresin of fern may 
lead to its quick rejection from the. stomach ; in such cases 
the viscus should be quieted by a few drops (3 to 5) of 
McMunn's elixir of opium, and a second dose of the anthel- 
mintic administered after the lapse of half an hour. 

Kameela (Rottlcra) is another good remedy for tape-worm, 
possessing the advantage of being in itself an aperient, and 
hence doing its work without the aid of purgatives. The 
same period of absolute fasting is necessary as when adminis- 
tering male fern, and on the morning of the day following 
the beginning of abstinence, two doses of fifteen grains of 
powdered kameela must be taken, at an interval of three 
hours. The drug may be exhibited suspended in syrup or 
in mucilage of acacia, a few drops of some aromatic oil being 
added in either case. A capital prescription, containing both 
kameela and male fern, is : 

R . Kameelse, gr. xxx 

Syr. acacise, f ^ ij . 

Misce, et adde — 

Oleoresinae filicis, f,^j _1 j 

Aquae cinnamomi, . f^j. M. 

Sig. — To be taken in two doses at an interval of three hours. 

A formula very similar to this has been in long and most 
successful use at the Children's Hospital, Philadelphia. 

In some cases oil of turpentine is very efficient, even when 
the remedies already mentioned fail. This may be given in 



374 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

one large dose, or in small doses frequently repeated. By 
the former method, from two to four fluidrachms are given 
in the morning after the usual fast, and followed in three 
hours by a dessertspoonful of castor oil, unless the bowels 
have been previously relieved. To carry out the latter, the 
following mixture may be used : 

K • Olei terebinthinae, 

Mellis, aa fjss 

01. menth. pip., gtt. vj 

Mucilag. acacise, q. s. ad f^iij. M. 

SlG. — Two teaspoonfuls every six hours. 

Every second day, preferably in the morning, two grains 
of calomel must be administered. 

Another useful drug is pumpkin seed ; this may be given 
in the form of an electuary, six drachms of the seeds being 
beaten up with sugar, and taken in one or two doses ; a brisk 
purge must be ordered after it. 

Koosso and its active principle, koossin, are recommended 
by some authorities. One drachm of the powdered drug 
suspended in water, or five or ten grains of koossin in capsule, 
are the proper doses for a child of eight years. To prevent 
nausea, it is better to break the dose into two or four ; addi- 
tional purgation is usually not required. 

After administering any anthelmintic, it is impossible to 
decide at once whether the tape-worm has been eradicated or 
not unless the head be discovered in the stools. The 
physician must not trust to the mother or nurse to find the 
head, but must look for it himself. The stools immediately 
following the action of the parasiticide must, therefore, be 
preserved until his visit ; the chamber in which they are 
received being filled with water containing a small quantity ol 
carbolic or salicylic acid. This is to be gently shaken in 
order to separate the worm from the faeces, and then allowed 
to stand for ten minutes ; during which the parasite, from its 



AFFECTIONS OF THE STOMACH AND INTESTINES. 375 

greater specific gravity, sinks to the bottom of the vessel. 
Next, the supernatant liquid is poured off, the vessel refilled 
with water, and the process repeated until the fluid remains 
nearly colorless. Then the head, if present, is readily found. 
Should the head not be discovered, it is impossible, although 
all symptoms may disappear, to give a positive opinion as to 
complete expulsion until two or three months have passed. 
Any return of symptoms requires a second course of treat- 
ment. 

Second: The removal of the alkaline mucus and the 
restoration of the normal condition of the alimentary canal 
are to be accomplished by the same attention to diet and the 
same therapeutic measures recommended when discussing 
chronic gastro-intestinal catarrh (p. 261 ct scq.). 



CHAPTER IV. 

TUBERCULOSIS OF THE MESENTERIC GLANDS AND 
INTESTINES. 

Tuberculosis of the mesenteric glands, and of the intes- 
tines, may occur as an element of the disseminated disease, 
may be secondary to tuberculous deposits in other parts of the 
body, or may be primary, the bacilli finding entrance into the 
system in contaminated food — usually milk from tuberculous 
cows. 



TUBERCULOSIS OF THE MESENTERIC 
GLANDS. (TABES MESENTERICA.) 

In this condition the glands of the mesentery, of the 
gastro-hepatic omentum, and the retro-peritoneal glands 
situated along the aorta are involved. It is a common form 
of the disease in childhood; "thus, of 127 cases of fatal 
tuberculosis in children, noted by Woodhead, these struc- 
tures were involved in 100, while Ashby states that of 103 
consecutive post-mortems on children dying of tuberculosis, 
in 62 there was tuberculous ulceration of the intestines ; in 
71, cheesy mesenteric glands; in 55, both ulcers and cheesy 
glands ; in 7, tuberculous ulcers without involvement of the 
glands ; and in 16, cheesy glands without ulcers."* 

The infection may be limited to a few of the glands, it may 
be merely an item in a chronic generalized tuberculosis, or it 
may be associated with ulceration of the intestines or involve- 



Osler, " American Text-book of the Diseases of Children.' 

376 



TUBERCULOSIS OF THE MESENTERIC GLANDS. 377 

ment of the peritoneum ; in the latter case it is most produc- 
tive of characteristic symptoms. The majority of cases occur 
after the third year. 

Etiology. — The predisposing causes are the same as those 
usually favoring tuberculous infection. 

Children who live in filthy, overcrowded, dark, and ill- 
ventilated houses are much more likely to be affected than 
those born to more fortunate surroundings ; coarse, over- 
stimulating, or bad food is also potent for evil, by irritating 
the intestinal mucous membrane and producing catarrh and 
follicular ulceration. 

Tuberculous disease of the lungs, of the cervical and bron- 
chial glands, or of the bones and joints, and tuberculous ulcer- 
ation of the bowels, are usual associates, and frequently 
predispose to the development of tabes mesenterica. In addi- 
tion, measles and scarlet fever, from their tendency to induce 
inflammation of the mucous membrane of the bowels and 
glandular hyperaemia, must be ranked as predisposing agents, 
and so, also, must whooping-cough. 

The essential cause is now recognized to be the bacillus 
tuberculosis. 

Symptoms. — The signs elicited by physical exploration 
of the abdomen, and the symptoms arising from the pres- 
ence of a mass of enlarged, tuberculous glands, are much 
more characteristic than the general features. The shape of 
the belly and the tension of its walls may be perfectly normal. 
Such is generally the condition during the earlier stages of 
the disease ; later, and particularly when there is intestinal 
ulceration, there is considerable distention. This is due either 
to the accumulation of flatus in the bowel or to the large size 
of the glandular tumor. In the first instance, the degree of 
prominence varies from day to day ; when marked, the wall 
is tense, percussion is tympanitic, and it is difficult or impos- 
sible to grasp the glands ; in the second, the enlargement is 
32 



37§ DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

constant and greatest in and about the umbilical region ; here 
there is resistance to the palpating hand rather than tension ; 
the tumor is easily felt, and percussion over it gives a dull 
sound ; around it, a tympanitic one. The tumor varies in 
size from that of a hen's egg to that of a double fist ; it is 
nodulated, hard, somewhat tender, slightly movable when 
small, and fixed when large. When of considerable size, the 
mass can readily be touched by placing the fingers on the 
umbilical region and pressing backward toward the spine. 
Otherwise, it is well to put one hand on each side of the 
abdomen and gently bring them together toward the median 
line, the patient being placed on his back with his shoulders 
and thighs elevated so as to relax the parietes. By this 
method it is possible to detect a tumor as small as a walnut. 

The secondary manifestations of the presence of a large 
mass of glands in the abdominal cavity are pains and cramps 
in the legs, due to pressure upon the nerves ; and cedema of 
the legs and distention of the superficial abdominal veins, 
from compression of the great venous trunks. The veins are 
often very prominent, and ramify over the wall of the belly to 
join those of the thoracic wall, which are also distended. 

If the glands in the notch of the liver be enlarged, direct 
pressure is exerted upon the portal vein, and ascites results ; 
this, however, is a very unusual symptom. 

In some instances the glands shrink and become calcareous. 
This change lessens the size of the tumor, diminishes the 
tension of the parietes, and, by relieving pressure, leads to the 
disappearance of the secondary derangements. 

Softening is another, but, fortunately, a rare termination. 
Adhesion may then take place between the gland and a loop 
of intestine, so that the softened matter is evacuated into the 
bowel without harmful result ; but should the discharge be 
directly into the peritoneal cavity, acute peritonitis is set up, 
and death soon follows. 



TUBERCULOSIS OF THE MESENTERIC GLANDS. 379 

The general symptoms depend for their development upon 
the condition of the intestinal mucous membrane. Usually 
there is tuberculous ulceration, with or without general catarrh. 

If ulceration and catarrh be associated, the child wastes ; 
grows pale and feeble ; presents a haggard appearance ; is 
fretful and peevish ; has a capricious appetite and much thirst ; 
complains of wandering pains in the abdomen, and is affected 
with diarrhoea, attended by the expulsion of offensive, dark, 
water}* stools, which, on standing, deposit flaky matter, 
mucus, and small, black blood clots. Sleep is restless, and at 
night the temperature rises one or more degrees above 
normal. 

When catarrh is absent, the bowels are often constipated ; 
the patient looks ill ; is pale and languid ; his muscles are 
flabby, and he has more or less flatulent pain in the belly ; 
but there is no marked wasting and none of the evidences of 
great impairment of general nutrition. 

Should there be no disease of the mucous lining of the 
bowels, flesh is retained ; the spirits and strength are good ; 
the appetite and bowels are undisturbed ; the temperature is 
normal and there is nothing to show ill health save some pallor 
of the skin. 

Diagnosis. — The only positive proof of the existence of 
tabes mesenterica is the detection, by palpation, of a glandular 
tumor. Particular caution must be given against the mistake, 
so frequently made, of attributing every case of abdominal 
distention to disease of the mesenteric glands. Prominence 
of the belly is a frequent symptom in children, and in the vast 
majority of cases depends upon intestinal catarrh. In this 
condition there is imperfect digestion and assimilation of food, 
and, consequently, debility, affecting the muscles of the 
intestines as well as the system generally. Xow, imperfectly 
digested food readily undergoes fermentation, with the pro- 
duction of flatus, and this distends the bowels ; the more so 



380 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

as they are wanting in tone from the weakness of their muscu- 
lar coat. Such inflation of the gut must lead, of course, to a 
prominent abdomen, but one which is uniformly tympanitic on 
percussion, moderately soft and flaccid to the touch, and 
entirely free from the signs of enlargement of the mesenteric 
glands. 

Again, distention of the superficial abdominal veins is 
merely an indication of obstructed circulation in the deep 
venous trunks, and only becomes a symptom of importance 
in the diagnosis of tabes mesenterica when hepatic disease 
can be excluded. 

Even should a tumor be felt, the question arises whether it 
may not be an accumulation of faeces. In the latter there is 
no tenderness ; the mass occupies the position of the trans- 
verse or descending colon, is oblong in shape, with its long 
diameter corresponding to the axis of the gut in which it is 
placed, and is so soft that it may be somewhat moulded by 
the pressure of the fingers. Should there be any doubt, an 
enema of warm normal saline solution must be thrown into 
the bowel and retained for a few moments, by firm pressure 
upon the anus. When expelled, this will bring away a quan- 
tity of light-colored, brittle matter, if the mass be due to faecal 
accumulation ; and the previously detected tumor will be found, 
on examination, to have disappeared or lessened in size. On 
the other hand, if the tumor be glandular, the expulsion of 
flatus and faeces, induced by the injection, only renders it still 
more prominent. 

The diagnosis must not be considered completed by the 
detection of the tumor, but must extend to the discovery or 
elimination of the different complications — ulceration of the 
intestines, tuberculous deposits in the lungs, and tuberculous 
peritonitis. 

Prognosis. — Tuberculosis of the mesenteric glands is 
dangerous, but the danger does not spring from the gland- 



TUBERCULOSIS OF THE MESENTERIC GLANDS, 38 1 

ular disease so much as from the conditions that precede and 
accompany it. 

When the sole discoverable lesion is swelling of the glands, 
and there is no rise in the evening temperature nor marked 
impairment of nutrition, the hope of subsidence of the en- 
largement and ultimate recovery, may be reasonably enter- 
tained. On the contrary, if there be wasting, diarrhoea, and 
fever, indicating ulceration of the bowels, secondary, perhaps, 
to chronic disease of the lungs, the prognosis must be grave. 
Again, the occurrence of tuberculous peritonitis renders the 
prospect most unfavorable. 

Treatment. — Much may be done in the direction of pro- 
phylaxis by keeping a strict watch upon the stomach and intes- 
tines in children having a tendency to tuberculosis, so as to 
remove any apparently trifling disorder as quickly as possible. 
Supplying good food, fresh, pure air, and warm clothing, and 
maintaining the activity of the skin are also important preven- 
tive measures. 

After the disease is established, much can be accomplished 
by attention to the diet and general regimen. In regulating 
the diet, it is necessary to take into consideration the catarrhal 
state of the intestinal mucous membrane usually present, and 
the almost useless condition of, at least, a number of the mesen- 
teric glands, and to select those articles which are absorbed 
in the stomach or taken directly into the blood-vessels, with- 
out the intermediate action of the lacteals and mesenteric 
glands. The food must be sufficient to maintain the general 
strength, but not so abundant as to overtax the process of 
digestion. The following may be taken as an average daily 
schedule of both diet and regimen for a child of four years, 
in whom there is no excessive wasting or weakness : 

On waking in the morning, say at 7 a. m., a thin slice of 
dry, stale bread, and three fluidounces of hot chicken-, mut- 
ton-, or veal-broth. 



382 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

At 8.30 a.m. a cold bath, given in this manner: Being 
taken from bed, the whole body is briskly shampooed with a 
soft towel until the surface is aglow. The child is next made 
to stand in a tub sufficiently filled with hot water to cover his 
feet and ankles, and two gallons of cold water, containing an 
ounce of sea-salt or concentrated sea-water, are slowly poured 
over his shoulders. The skin is then thoroughly dried and 
rubbed until reaction is established ; the child is wrapped in 
a blanket and put back to bed for half an hour. On rising, 
the abdomen should be completely enveloped in a flannel 
binder, and the body clad in woolen underclothing from head 
to foot. 

At 9.30 a. m., breakfast. — A soft-boiled egg and two slices 
of stale bread. 

From 10.30 a. m. to 12 m. — A walk or romp in the open 
air, in good weather. 

At 12 m., lunch. — Six raw oysters or a bit of sweetbread 
or fish, and a slice of dry, stale bread. 

At 3 p. m., dinner. — Six fluidounces of beef-, mutton-, or 
chicken-broth ; a bit of minced roast beef, beef-steak, roast 
mutton, chicken, or wild fowl. A moderate quantity of puree 
of spinach, stewed celery, boiled cauliflower, or other non- 
farinaceous vegetable, and one or two slices of dry, stale 
bread. No dessert except junket occasionally. 

At 7 p. m., supper. — Same as lunch, alternating the fish, 
sweetbread, or oysters. 

Nothing should be taken for drink but filtered water or, 
better still, good spring-water.* 

When there is much emaciation and weakness, the morning 
bath must be omitted or substituted by a simple warm spong- 
ing ; and some stimulant, as a teaspoonful of old whiskey, 
should be given three times daily. 

* Directions for Philadelphia. 



TUBERCULOSIS OF THE INTESTINES. ' 383 

Diarrhoea demands an exclusive liquid diet, and it is advis- 
able to artificially digest the meat broths and milk, which 
must form the basis of this. 

The most useful drugs are cod-liver oil, syrup of hydriodic 
acid, and the syrup of the iodide of iron, since the indications 
are to build up the general health and restore the glands to a 
healthy condition. The former can be given as an emulsion 
with lactophosphate of lime in two-drachm doses three times 
daily, after eating, at the age of four years ; either of the latter 
in fifteen-drop doses after meals. 

Locally, some good may result from the daily inunction of 
a weak mercurial or iodine ointment ; for example : 

B . Ung. iodi comp., . . gij 

Ung. belladonna, gj 

Ung. aqure rosae, 3 v. M. 







R. Ung. hydrargyri, . giij 

Adipis, 3 v. M. 



Of either, a piece as large as a cherry may be rubbed into 
the skin over the tumor once every day. 

Other remedies, of course, are required to arrest diarrhoea, 
or to relieve the different complications that may arise. 

Should the circumstances of the patient permit, change of 
residence to some locality having an equable climate, a brac- 
ing atmosphere, and a dry, porous soil, will greatly assist in 
effecting - a cure. 



TUBERCULOSIS OF THE INTESTINES. 

Tuberculosis of the intestines may occur as a primary affec- 
tion, but in the majority of instances it is a part of a general 
infection, and secondary in character. The lesions are chiefly 
confined to the ileum, and primarily affect the solitary follicles 



384 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

and Peyer's patches, particularly those about the ileo-csecal 
valve. The follicles become enlarged from tuberculous infil- 
tration, then undergo caseous degeneration and softening, with 
the formation of isolated ulcers in the case of the solitary 
glands, and clusters of coalescing ulcers in that of the patches 
of Peyer. From having, at first, the shape of the follicles and 
patches, they gradually extend by a similar process of cor- 
puscular infiltration, caseation, and softening in the surround- 
ing tissues. The fully formed ulcers are irregularly oval in 
shape, with their greatest diameter directed transversely to the 
axis of the gut ; their edges are indented, thick, and some- 
what undermined ; their floors are red or gray, and formed by 
one or the other tissue of the intestine, as far down as the 
peritoneum, according to the depth of destruction. Perfora- 
tion is rare on account of localized adhesive peritonitis. 
Tubercles may be found in the tunica adventitia of the small 
arteries and lymphatics, or on the reddened and cloudy peri- 
toneal surface corresponding to the ulcers. Cicatrization takes 
place rarely, but may be the cause of stricture. 

The uninvolved mucous membrane is congested, thickened, 
and softened. The mesenteric glands are enlarged and cheesy, 
and miliary tubercles are usually found in the lungs or else- 
where. 

Etiology. — The disease is met with in children who have 
passed the fourth year, and in whom the tuberculous diathesis 
exists. Bad hygiene, bad food, and exposure act as predis- 
posing causes, by interfering with general nutrition and paving 
the way for the development of accidentally introduced bacilli. 
An unsuitable diet, too, may indirectly lead to this form of 
ulceration, by bringing about an abnormal and more suscept- 
ible condition of the lining membrane of the bowel. 

Symptoms. — In addition to the features indicating a tuber- 
culous tendency, the child, after suffering for a variable time 
from the symptoms of simple intestinal catarrh with either 



TUBERCULOSIS OF THE INTESTINES. 385 

constipation or diarrhoea, begins to have fever and to pass 
excessively offensive stools, composed of dirty-brown liquid 
that, on standing, deposits flocculi, mucus, pus, and small black 
clots of blood, and which a microscopic examination shows to 
contain tubercle bacilli. There is colic preceding the evacua- 
tions ; moderate distention of the belly, with at times tension 
of the parietes over the right iliac region, and tenderness on 
pressure there. Abdominal palpation may reveal enlargement 
of the mesenteric glands, and physical examination of the 
chest the evidences of pulmonary phthisis. Such cases usually 
result fatally, after a more or less protracted course, the direct 
causes of death being tuberculosis of the lungs or of the 
meninges of the brain. 

Treatment. — Pure air, warm clothing, good food, and tonics 
comprise the measures of treatment. The best of the tonics 
is cod-liver oil, which, in these cases, often seems to lessen the 
tendency to diarrhoea. Half to one teaspoonful three times 
daily is quite enough for a child of five years. It may be 
given combined with maltine, or in an emulsion with lacto- 
phosphate of lime, or the compound syrup of the hypophos- 
phites. The following is an admirable formula : 

R. Olei morrhuoe, f^ij 

Ext. malt (dry), . ^iv 

Calcii hypophos., 

Sodii hypophos., aa gr. xvj 

Potassii hypophos. , gr.viij 

Glycerini, f^ij 

Pulv. acaciae, 31J 

Aquae, q. s. ad f ^ iv. M. 

SiG. — One teaspoonful three times daily. 

Creasote is also a useful remedy, beginning with doses of 
one minim three times daily and gradually increasing each dose 
to five or even ten minims ; it may be administered in a mix- 
ture or in the form of a pill or perle. 

In addition to this general treatment, attention must be paid 



386 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

to the intestinal condition. A dressing of cotton, covered 
with oiled-silk, should be placed over the right iliac region or 
over the whole abdomen. Internally, subcarbonate of bismuth 
with compound ipecacuanha powder, nitrate of silver, and 
intestinal antiseptics are of service, and, if there be severe 
abdominal pain, enemata containing laudanum may be em- 
ployed. 



CHAPTER V. 
AFFECTIONS OF THE LIVER. 

Hepatic diseases do not occur so frequently during child- 
hood as in adult life. Fatty and amyloid changes are the 
most common affections ; syphilitic disease, cirrhosis, tuber- 
culous deposit, and parenchymatous inflammation stand next 
in the order named ; while echinococcus is very rare, and 
cancer almost unknown. Jaundice, on the contrary, is often 
met w 7 ith, but this condition, though a complex and striking 
one, is simply an indication of disease of the viscus itself, or 
of its excretory duct. Congestion of the organ is also com- 
mon. 

JAUNDICE. 

Icterus, irrespective of the age at which it occurs, is char- 
acterized by yellowness of the skin and conjunctivae, clay- 
colored stools, and yellow-brown urine. During the first few 
days of life, especially after a difficult and tedious birth, there 
is apt to be intense congestion of the skin, followed, as the 
redness fades, by a brownish-yellow discoloration. This 
appears on the second or third day, and disappears by the 
tenth. 

It is not jaundice, for it is entirely independent of liver dis- 
order, and there is no yellowness of the conjunctivae, and no 
alteration in the faeces or urine. A form of true jaundice, 
however, does occur in the newborn, termed icterus neo- 
natorum, which may be studied before describing the condi- 
tion as it is seen in later childhood. 

387 



388 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

ICTERUS NEONATORUM. 

Both mild and dangerous types of this variety of jaundice 
are met with. 

The mild type occurs in infants prematurely born, or weak 
from other causes ; in those early exposed to the depressing 
action of cold, dampness, and foul air, and particularly in 
those who are born partly asphyxiated after tedious labor. 
It is difficult to understand the exact method in which these 
causes act. Cold undoubtedly produces catarrh of the duo- 
denal mucous membrane, and plugging of the bile-duct by 
mucus ; the others, the last especially, act, in all probability, 
by altering the hepatic circulation. At birth there is a sudden 
transference of the blood supply from the umbilical to the 
portal vein, a change — according to Frerichs — temporarily 
followed by comparative emptiness of the blood-vessels of 
the liver, a diminution of vascular tension, and the passage 
of bile into the blood. Weber attributes the jaundice to 
pressure from congestion and cedema, the result of an arrest 
of the circulation in the umbilical vein before the establish- 
ment of respiration — conditions present in infants born semi- 
asphyxiated. Birch-Hirschfeld has demonstrated that a 
dense areolar sheath surrounds the vessels in the notch of 
the liver and extends into the viscus along with the portal 
vein ; this becomes cedematous and greatly swollen when 
there is venous obstruction in the liver during difficult par- 
turition, and, by pressure, obstructs the flow of bile into the 
intestine. 

The grade of jaundice in this type varies considerably. 
Sometimes the yellow discoloration is confined to the face, 
chest, and back ; the conjunctivae are but lightly tinged ; the 
urine and faeces are unaltered, and after three or four days 
the trouble is at an end. In other cases, the yellowness ex- 
tends to the abdomen and arms ; the conjunctivae are dis- 
tinctly yellow ; the urine is dark and stains the diapers, but 



AFFECTIONS OF THE LIVER. 389 

the stools still retain their natural color — golden yellow ; the 
duration is about seven days. The best-developed instances 
present universal and moderately deep discoloration of the 
skin; the conjunctivae are very yellow ; the urine brownish, 
and the stools clay-colored. With this degree of jaundice 
there is malaise, loss of appetite, constipation, and enlarge- 
ment of the liver ; the lower edge of the right lobe often 
extending below the costal border as far as the umbilicus. 

Occasionally, instead of constipation, there is diarrhoea, 
with moderate heat and tenderness of the belly, and a quick 
pulse, indicating severe intestinal catarrh. These cases 
recover after a fortnight or more, though occasionally 
diarrhoea arising and persisting in a feeble infant, is sufficient 
to determine a fatal issue. 

The treatment is simple. The infant must be kept in a 
warm, well-ventilated room ; the activity of the skin must be 
maintained by bathing, and chilling prevented by proper 
clothing. Constipation is to be relieved by fifteen or twenty 
drops of castor-oil, a soap suppository, or an enema, and, if 
the skin be slow 7 in resuming its normal color, it is well to 
prescribe an alkali, as : 

lje . Sodii bicarbonatis, gr. xxxij 

Aq. menth. pip., 

Syrupi, aa f 3 ss 

Aquae, q. s. adf^ij. M. 

SlG. — One teaspoonful three times daily. 

The grave type depends upon congenital malformation of 
the bile-ducts and gall-bladder, compression of the bile-ducts 
by syphilitic inflammation and growths, and umbilical arteritis 
and phlebitis. 

(a) Congenital malformation is rare, but when it occurs is 
liable to affect several members of the same family in succes- 
sion ; boys suffer twice as often as girls. There are a number 
of varieties : thus, the gall-duct may be converted into a 



390 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

fibrous cord ; the ductus communis may be contracted, 
obliterated, or absent ; the gall-bladder may be rudimentary 
and the ducts absent ; or all the ducts may be wanting. 
Whatever the condition, the result is enlargement of the liver 
with cirrhotic change, more or less marked in proportion to 
the duration of life. The organ is dark green or almost black 
in color, feels unnaturally firm to the touch, and under the 
microscope shows an excess of connective tissue. 

From one to two weeks after birth the retained bile begins 
to give rise to jaundice ; this appears as a slight yellowness 
of the skin, and steadily grows more distinct, though it varies 
considerably in intensity from day to day ; at the same time, 
the conjunctivae are stained and the urine dark-colored. 
After a day or two, the liver begins to encroach upon the 
abdominal cavity and rapidly enlarges ; the spleen, too, 
increases in size, and these two lesions, together with flatulent 
distention of the bowels and occasional ascites, produce 
decided prominence of the belly. In spite of a uniformly 
good appetite, there is constant wasting. The bowels act 
sluggishly, the faeces are offensive, clay-colored, or dark 
green, from the presence of altered blood, and dilated 
hemorrhoidal veins can often be seen by inspecting the anus. 
Another frequent symptom is oozing of blood, either arterial 
or venous, from the umbilicus. This hemorrhage is capillary 
in nature, and usually begins at night, and soon after the fall 
of the navel string, an event that occurs between the fifth 
and ninth day. It may be combined with bleeding from the 
nose, mouth, stomach, or bowels, and is exhausting and 
always difficult to control. 

This form of jaundice ends in death. When umbilical 
hemorrhage occurs, the course is short, varying from a few 
hours to six or seven days ; in other cases, life may be pro- 
longed as many months, and death result from some inter- 
current disease. In the latter class, the secreting elements of 



AFFECTIONS OF THE LIVER. 39 1 

the liver are so far crippled by the constantly progressing 
cirrhosis that little bile is formed, and the yellowness of the 
surface fades, or almost entirely disappears, before life ends. 

(£) Syphilitic inflammation of the liver with its lesions and 
symptoms will be referred to in another place (see page 401). 

(<r) Inflammation of the umbilical blood-vessels is due to 
septic infection entering at the umbilical wound. The infect- 
ing agent is apparently identical with that producing puerperal 
fever in the mother, the same pyogenic germs frequently hav- 
ing been discovered in the blood of infants so affected. In 
consequence, the liver undergoes marked degenerative changes; 
the connective tissue about the portal vein and its branches 
becomes swollen and presses upon the bile-ducts, and from 
this, as well as from alterations in the crasis of the blood, 
jaundice results. 

Discoloration of the skin makes its appearance a few days 
after birth and rapidly increases ; the urine is very dark, and 
the stools are scanty and passed at long intervals. The face is 
livid and pinched ; the hands and feet are purple ; petechias 
appear under the skin ; the abdomen is distended by flatus 
and by enlargement of the liver and spleen ; there is tender- 
ness with fluctuation on palpation, and blood or bloody pus 
exudes from the umbilicus. The tongue is dry, there is little 
appetite, and the stomach rejects what food is taken, together 
with quantities of greenish mucus. Pyrexia is noticeable 
from the beginning, and becomes more marked as the disease 
progresses ; the pulse is quick and the breathing hurried. 

The course is always short, and the invariably fatal termi- 
nation may be preceded by convulsions and coma. 

Treatment in either variety is most unsatisfactory ; little 
can be done beyond the employment of measures to maintain 
the vital forces as long as possible. Umbilical hemorrhage 
may be arrested by the application of Monsel's solution, or, 
if this fail, by inserting two hare-lip pins through the skin at 



39 2 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

the root of the navel and twisting a ligature tightly around 
them in the form of a figure of eight. 

Syphilitic inflammation demands appropriate constitutional 
remedies, and in pyaemic cases the abdominal tenderness must 
be relieved by warm fomentations and sedative applications. 

ICTERUS IN OLDER CHILDREN. 

Jaundice in late infancy and childhood usually depends 
upon catarrh, extending from the mucous membrane of the 
duodenum into the ductus communis ; sometimes it is due to 
plugging of the duct by inspissated bile ; and, again, to oc- 
clusion by the entrance of a lumbricoid worm. Certain 
structural lesions of the liver, poisoning by phosphorus, and 
miasmatic influences also produce it. 

Catarrhal jaundice — the only form necessary to consider in 
this connection — presents the features so common to, and so 
characteristic of, the same condition in adults. Briefly stated, 
there is more or less yellow or brownish-yellow discoloration 
of the skin, with troublesome itching, yellowness of the con- 
junctivae, porter-like urine, and clay-colored stools, devoid of 
the natural faecal odor. Other symptoms are anorexia, crav- 
ing for acid drinks, a yellow-furred tongue, disordered diges- 
tion, listlessness, slowness of the pulse, slight reduction of 
the surface temperature, and disturbed sleep. The liver may 
be somewhat enlarged, projecting two inches or more below 
the costal border, and tender, or even painful, on pressure. 
The result is always favorable, and the duration rarely longer 
than two or three weeks. 

Treatment. — Warm clothing, daily bathing followed by 
gentle friction to promote the activity of the skin, and a diet 
based on the same plan as for intestinal catarrh, are the first 
requisites. 

The medicinal treatment can be begun by a moderate dose 
of calomel, followed by a saline ; but if a laxative be required 



AFFECTIONS OF THE LIVER. 393 

later, the drugs that stimulate the secretion of the liver and 
act upon the upper bowel must be excluded, and those selected 
which affect the lower segment, as aloes and castor oil. 

Duodenal catarrh — the causal factor — is most speedily re- 
moved by alkalies. Four fluidounces of some saline water, 
as Kissingen or Vichy, should be drunk at each meal, and 
the following mixture taken : 

R . Ammonii chloridi, £ ij 

Aq. menth. pip., f^iij- M - 

Sig. — One teaspoonful, diluted, three times daily after meals, for a child six 
years old. 

Or— 

R. Sodii phosphatis, gj 

Ext. pancreatis (Fairchild's), gr. xxiv 

Pulv. rhei, gr. vj. 

M. et ft. chart. No. xij. 
SlG. — One, suspended in water, three times daily after food. 

Nux vomica is also useful, and two or three drops of the 
tincture may be administered thrice' daily before eating. 



CONGESTION OF THE LIVER. 

Congestion of the liver may occur as an active or passive 
condition, and is most frequent in children of four years of 
age and upward. 

Morbid Anatomy. — There is an increase in the size, 
weight, and density of the organ, and its peritoneum is tense 
and shining. On incision, blood flows freely, and the section 
presents a mottled or " nutmeg " appearance, partly from 
dilatation of the intralobular veins and partly from staining of 
the cells by retained bile. In long-standing cases, those due 
to cardiac disease, for example, the cells in immediate prox- 
imity to the dilated intralobular veins atrophy ; those near 
them are stained with bile, and those most distant undergo 
33 



394 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

fatty degeneration. In time the atrophied cells disappear ; 
their place is taken by connective tissue, which shrinks and 
produces a cirrhotic condition, the surface of the liver becom- 
ing granular and the capsule thickened. 

Etiology. — Even in health the amount of blood in the 
hepatic vessels varies from time to time, and there is always 
a temporary increase during the process of digestion. This 
normal hyperemia readily becomes abnormal and continuous 
— active congestion — when there is habitual overfeeding ; 
when the food is highly spiced and too stimulating ; and 
when insufficient exercise is taken. Congestion is often pro- 
duced by chills, whether resulting from exposure to cold or 
from the poison of malarial fever, since, in either case, the 
blood is driven from the surface to the interior of the body. 
Cardiac and pulmonary disease, by obstructing the return of 
blood from the lung and overfilling the vena cava and portal 
vein, are the chief causes of passive congestion. This condi- 
tion also results from chronic malarial poisoning. 

Symptoms. — In active congestion the skin is sallow, or, 
together with the conjunctivae, distinctly, but not intensely, 
jaundiced. There is malaise, headache, yellow furring of the 
tongue, anorexia, nausea, relaxed bowels with clay-colored, 
offensive stools, and dark-colored urine loaded with lithates. 
Pain in the right hypochondrium is usually present, and, as 
this is increased by turning upon either side, the patient 
maintains a dorsal position ; there is also tenderness in this 
region, and the suffering is increased by coughing or deep 
breathing. On palpation, the right lobe of the liver can be 
detected, extending two or three inches beyond the costal 
border, while sometimes at its edge is felt the gall-bladder 
distended into a pyriform tumor of variable size. At the 
same time the upper limit of percussion dulness begins in the 
third interspace, or at the level of the third rib, instead of the 
fourth interspace, as in health. 



AFFECTIONS OF THE LIVER. 395 

In passive congestion the hepatic symptoms are associated 
with albuminuria and oedema of the feet and legs, and are 
often marked by the features of the causal conditions. 

Diagnosis. — Many instances of disordered digestion, with 
the expulsion of putty-like, undigested material from the 
bowels, are attributed to congestion of the liver, when in 
reality the gastro-intestinal tract alone is at fault. Such a 
mistake can be avoided, if it be remembered that to establish 
the existence of the hepatic disease it is necessary to have 
enlargement of the organ, with pain and tenderness, jaundice 
and clay-colored, offensive stools, combined with disturbance 
of the functions of the stomach and intestines. 

Extension of the liver a finger's breadth or more below 
the costal border does not absolutely indicate enlargement, 
since this often occurs without disease, in short-chested chil- 
dren, and in those whose chests are contracted and deeply 
grooved by rickets. Downward displacement and apparent 
enlargement may also be caused by pleuritic and pericardial 
effusions, and by emphysema of the lungs.- On the other 
hand, an enlarged liver may be completely under cover of the 
ribs, for, in addition to being normally high in the thorax, it 
may be pushed upon by a collection of fluid or a growth in 
the abdominal cavity, or drawn up through the shrinking of 
a collapsed or indurated lung. It is essential, therefore, to 
fix the position of the upper limit by percussion, as well as 
the lower edge by palpation, before forming a conclusion. 

Prognosis. — The course of the active form is short, and 
there is no danger unless the child be greatly reduced by 
previous ill health. In passive congestion the duration and 
result correspond to, and depend upon, the gravity of the 
determining lesion. 

Treatment. — In acute cases the child may be put to bed, 
or, if not ill enough to be so confined, should be kept 
within doors. The abdomen must be protected by a flannel 



396 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

binder or a layer of cotton batting covered with oiled silk, 
and the skin kept active by a daily warm bath, administered, 
in walking cases, just before retiring to bed. Too much food 
of any kind is bad ; meat and highly seasoned dishes are to 
be excluded from the diet; and it is best not to extend the 
list beyond milk, mutton- or veal-broth, fish, bread, and plain 
light puddings, as rice and milk. 

In the beginning, a child of six or eight years should get 
the following powder : 

R. Hydrargyri chlorid. mit., gr. ij 

Pulv. ipecacuanhae, gr. ss 

Sacchari, gr. v. 

M. et ft. chart. No. j. 
Sig. — To be taken in the evening and followed, next morning, by a teaspoon - 
ful of magnesia. 

Subsequently, five grains of chloride of ammonium or 
phosphate of sodium should be given after food, and a small 
tumbler (five fluidounces) of Vichy taken with each meal. 

Aloes and the salines are the best remedies to relieve con- 
stipation during the course of the attack. When convales- 
cence is established, regular exercise in the open air must be 
insisted upon and a plain diet maintained. Change of air is 
often most useful to break up the "bilious habit." 

In passive cases, treatment must be directed chiefly to the 
producing disease of the heart or lungs ; when chronic 
malarial poisoning is the etiological factor, antiperiodics are of 
little avail until the hepatic congestion is relieved. 



FATTY LIVER. 

Enlargement of the liver due to fatty infiltration or degen- 
eration is usually a secondary condition in childhood. 

Morbid Anatomy. — The liver is increased in all its dimen- 
sions, its surface is yellowish and oily, its margins rounded, 



AFFECTIONS OF THE LIVER. 397 

and its texture doughy. On section, the cut surface is dis- 
tinctly yellow, mottled with brownish-red spots, and if a bit 
be put under the microscope, abundant granules and globules 
of fat are seen. 

Etiology. — One cause of fatty liver is an excess of fari- 
naceous food. Then the deposition is physiological and 
transitory, the excess of carbohydrates supplied from without 
being deposited in the liver in the form of fat. The second 
cause is chronic, exhausting disease, such as tubercle, rickets, 
caries of bone, intestinal catarrh, and syphilis. Here the fat 
is absorbed from the subcutaneous and other fat-containing 
tissues of the body. The lesion may also be produced by 
acute affections, as measles, variola, scarlatina, and typhoid 
fever, and by accidental poisoning with arsenic or phos- 
phorus. 

Symptoms. — It is only in well-marked cases that special 
features are developed. An increase in the bulk of the liver, 
with a rounded inferior margin, may be detected by percus- 
sion and palpation ; but this is frequently impossible on 
account of the tendency the organ has, from its softness, to 
fall away from the abdominal wall. There is a sense of 
weight in the right hypochondriac region and disturbed 
gastro-intestinal function due to portal obstruction. Jaundice 
and ascites are absent, and there is neither pain nor tender- 
ness over the viscus. 

The diagnosis is not difficult when enlargement, softness, 
and blunting of the edge of the viscus can be detected by 
examination. 

The prognosis depends upon the cause rather than the 
degree of change ; occurring in the course of a protracted, 
wasting disease, fatty infiltration shows dangerous impairment 
of nutrition. When fatty degeneration of the viscus is pro- 
duced by acute affections or by accidental poisoning, the 
result is invariably unfavorable. 



39$ DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Treatment. — Beyond a rigid exclusion of farinaceous and 
fatty foods from the dietary, all remedies must be directed to 
the relief of the originating disease. 



AMYLOID LIVER. 

Amyloid degeneration of the liver is moderately common 
in childhood, usually constituting a part of a widespread 
degenerative change affecting several of the abdominal viscera. 

Morbid Anatomy. — The disease consists in a more or less 
complete infiltration of the cells by a peculiar translucent, 
refracting substance, possessing the property of fixing iodine 
and assuming a mahogany-brown color, which, on the appli- 
cation of sulphuric acid, changes to green, blue, violet, or 
red. The infiltration begins in the hepatic arterioles and 
capillaries, and at first is limited to the middle zone of the 
lobules ; thence it extends to the periphery and centre, de- 
stroying the normal elements of the cells and converting 
them into irregularly shaped, glassy-looking blocks. Fatty 
infiltration is often associated. Uniform enlargement ; in- 
creased density ; yellowish-gray color ; smooth, shining peri- 
toneum ; thin edges, and the exposure, on section, of dry, 
homogeneous, glistening surfaces, are the gross charac- 
teristics. 

The spleen, kidneys and lymphatic glands are often similarly 
altered, and sometimes the mucous membrane of the stomach 
and intestines. 

Etiology. — Amyloid degeneration of the liver is always 
produced by some chronic disease attended by suppuration 
and purulent discharge. Empyema with a fistulous opening 
in the chest-wall ; dilated bronchi with copious muco-purulent 
expectoration ; tuberculous abscess ; chronic pulmonary tu- 
berculosis ; suppurative diseases of the bones and joints, and 
constitutional syphilis, are the most frequent causes. It occurs 



AFFECTIONS OF THE LIVER. 399 

at any age, but is more frequent after the fifth year, and in 
boys than girls. 

Symptoms. — There are few rational symptoms other than 
those belonging to the originating disease. Tenderness and 
pain in the hepatic region are absent, and so, too, are jaundice, 
distention of the superficial abdominal veins, and ascites ; un- 
less the glands in the fissure of the liver be coincidently en- 
larged by waxy deposit, when, from pressure upon the portal 
vein and bile-ducts, the last three phenomena may be developed. 
The patient complains of weight, discomfort in the right hypo- 
chondrium, and is weak, wasted, and anaemic, with pale, sallow 
skin, clubbed fingers, and cedematous feet and ankles. When 
the kidneys are involved, the urine is increased in quantity, 
has a low specific gravity (about 1.014), is pale, lemon-colored, 
and contains albumin, and, at times, hyaline tube-casts. Dropsy 
of the extremities is due in great part to this complication. If 
the stomach and intestines be implicated, there is a tendency 
to vomiting and diarrhoea. 

Physical examination yields very characteristic signs. The 
abdomen is prominent, especially over the upper third, and 
both percussion and palpation show that the liver is greatly 
and uniformly enlarged. The upper margin of dulness is 
higher, by an inch or more, than normal ; while the lower 
edge of the right lobe, somewhat blunted, but perfectly well 
defined, can often be felt as low down as the level of the 
umbilicus. The portion uncovered by the ribs feels very 
dense and firm, and perfectly smooth, except where broken 
by the natural fissures. 

The spleen can often be detected projecting as a hard mass 
from beneath the left costal border. The absence of enlarge- 
ment, however, is no proof against the existence of amyloid 
change in the organ ; in about half the cases there is no 
alteration in size. 

In course, the disease is always slow. 



400 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Diagnosis. — This is readily made from the physical signs 
furnished by the liver and spleen ; the absence of jaundice 
and ascites ; the previous history of cachexia and suppuration ; 
the character of the urine ; the anaemia, and the gastro- 
intestinal symptoms. 

Congestion of the liver with consequent enlargement has a 
different clinical history, rarely occurring in cachectic or 
anaemic cases. A fatty liver, while large, is soft and yielding 
to the touch, and is unattended by albuminuria or by increase 
in the size of the spleen. 

Prognosis. — The prospect of ultimate recovery is better 
in children than in adults, for, provided the cause of the 
degeneration can be removed, it is quite possible for the liver 
to return to its natural dimensions and to an apparently 
healthy condition, through the active reparative power always 
present in early life. Nevertheless, amyloid change in the 
liver adds greatly to the danger of the originating disease, 
and is fatal in most cases. 

Treatment. — It is almost needless to state that attention 
must first be given to the removal or amelioration of the 
cause. It is much more difficult to cure the disease when 
once developed, than to prevent it by checking chronic 
suppuration, removing carious bone, healing diseased joints, 
energetically treating constitutional syphilis, and building up 
the health in cachectic subjects. 

To combat the disease itself, the diet must be as nutritious 
as the activity of digestion will permit ; a moderate quantity 
of alcoholic stimulants must be taken daily ; the child must 
be properly clothed, to prevent chilling, and must live as 
much as possible in the sunlight and open air, or, if confined 
to the house, in a light, airy room. Alkalies, iron, and 
iodine are the most useful drugs. 

Of alkalies, chloride of ammonium is the best, and it may 
be given in combination with a bitter, as : 



AFFECTIONS OF THE LIVER. 40 1 

]£ . Ammonii chloridi, 3 ij 

Inf. gentianse comp., f^ n j- M. 

Sig. — One teaspoonful four times daily at the age of six years. 

It is often well to combine iron with the ammonia salt, for 
example : 

$. Tr. ferri chloridi, f 3 j 

Ammonii chloridi, 3 i j 

Inf. calumbse, q. s. ad f^iij. M. 

Sig. — One teaspoonful three times daily. 

Another good way of administering iron is in the form of a 
modified Basham's mixture : 

R . Tr. ferri chloridi, f £j 

Acid, acetici dil., f^iss 

Liq. ammonii acetatis, f^x 

Elix. aurantii, f3 v 

Syrupi, f£j 

Aquse, q. s. ad f^vj. M. 

Sig. — One tablespoonful four times a day. 

This formula is particularly useful when there is kidney 
complication with oedema. 

Iodine is most efficient if there be a syphilitic taint ; it may 
be given in the form of iodide of potassium, five grains or 
more three times a day, with a bitter infusion ; or syrup of 
hydriodic acid can be employed in doses of fifteen to thirty 
drops, diluted, thrice daily. 

Complications must be met as they arise. Vomiting, by 
creasote, bismuth, and counter-irritation to the epigastrium ; 
diarrhoea, by astringents, with small doses of opium ; and 
dropsy, by diaphoretics and diuretics. 



SYPHILITIC INFLAMMATION OF THE LIVER. 

Syphilitic hepatitis is frequently encountered in the new- 
born, though rare in more advanced childhood. 

Morbid Anatomy. — The liver may be the seat of acute 
34 



402 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

swelling, which, without showing marked gross alteration, is 
associated with a diffused growth of connective-tissue elements ; 
again, there may be a localized gummatous change ; and, 
finally, the inflammatory process may be confined to the 
septa — -peripylephlebitis syphilitica. The proliferation of 
connective tissue takes place both between the hepatic islands 
and in their interior, thus differing from cirrhosis, where the 
increase is only between the lobules. When jaundice occurs, 
the small bile-ducts are thickened and occluded by epithelial 
cells, and the organ is enlarged, and brownish-yellow in 
color. 

Symptoms. — In mild cases these are few and uncharac- 
teristic ; in those that are grave there are jaundice, ascites, 
hemorrhage from the umbilicus and intestines, ecchymosis of 
the skin, subnormal temperature, rapid wasting, and often 
syphilitic lesions of the skin and mucous membranes. On 
abdominal exploration, the liver is found to be enlarged and 
hard, and the spleen increased in size. 

Diagnosis. — The early age, the history of an inherited 
taint, the association of enlargement of the liver with jaundice 
and ascites, make this a matter of little difficulty in cases that 
are at all marked. 

Prognosis is unfavorable, though the opinion must rest 
upon the degree of cachexia. Goodhart states that all of his 
cases proved remarkably amenable to mercurial treatment, 
but this does not correspond with the experience of other 
observers. 

Should deep jaundice, ascites, and hemorrhage occur, death 
is the almost invariable end. 

Treatment. — As in other syphilitic affections, mercurials 
must be followed by tonics. One-eighth of a grain of 
calomel, or one grain of mercury with chalk, may be 
administered morning and evening ; or ten grains of mercurial 
ointment may be rubbed into the skin once a day, either 



AFFECTIONS OF THE LIVER. 403 

directly by the ringers of the nurse, or by being smeared 
upon the flannel binder. 

After the liver has been reduced in bulk and other manifes- 
tations of the poison are under control, syrup of the iodide of 
iron, in two-drop doses three times daily, is the most efficient 
tonic. 

Iodide of potassium is also useful ; it acts best when com- 
bined with chloride of ammonium, as : 

R . Potassii iodidi, gr. xxiv 

Ammonii chloridi, gr. xxxvj 

Syrup, sarsaparillae corap. , f Jss 

Aquae, q. s. ad f^iij. M. 

SlG. — Teaspoonful three times daily for an infant of one month. 

In those fortunate instances that yield to treatment, splenic 
enlargement disappears less rapidly than that of the liver, and 
requires the daily application of compound iodine ointment 
diluted in the proportion of one part to seven of lard. 



CIRRHOSIS OF THE LIVER. 

In childhood, cirrhosis must be classed among the uncom- 
mon diseases of the liver ; the fact of its occasional occurrence, 
however, has been abundantly proved by post-mortem exam- 
inations. 

Morbid Anatomy. — There are two forms : namely, the 
atrophic and the hypertrophic. 

In atrophic cirrhosis, or hob-nailed liver, the organ is con- 
tracted and dense in texture, with nodulated surfaces, thin 
edges, and thickened capsule ; on incision, the cut surface is 
grayish-yellow in color, and traversed by a distinct fibrous 
network. The lesion begins as a chronic inflammatory con- 
dition of the branches of the portal vein, and consists of a 
rapid development of embryonic cells, with subsequent con- 
version into fibrous tissue. The new-formed tissue follows 



4O4 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

the branches of the portal vein within the substance of the 
gland ; extends into the interlobular spaces and forms meshes 
of variable size, but always embraces several lobules. Some 
enlargement may attend the primary formation of embryonal 
tissue, but the shrinking of cicatricial contraction invariably 
follows ; the cells become flattened and atrophied ; there is a 
marked reduction in size, and the circulation in the hepatic 
portal vessels is greatly obstructed. The smaller bile-ducts 
are little affected, and blood for the nourishment of the organ 
and for the formation of bile is carried by vessels developed in 
the neoplasm. 

In hypertrophic or biliary cirrhosis the liver is usually 
enlarged, perhaps to twice its normal dimensions. It has a 
smooth surface, a thin edge, and on section is orange-yellow 
or green. The fibroid growth begins around the intralobular 
branches of the bile-duct, and envelops and isolates separate 
lobules ; it follows the ramifications of the bile-ducts ; is more 
diffused than in the atrophic form, and denser and thicker in 
some portions than in others. The portal circulation is not 
necessarily embarrassed, but the biliary ducts are obstructed 
and dilated, and have their epithelial lining increased in 
thickness. 

In both forms there is enlargement of the spleen, and in 
some cases there is an association of the characteristic lesions. 

Etiology. — The causes are, as yet, ill determined. Alco- 
holic excess, the prime factor in adults, is, of course, inopera- 
tive in children, except in very rare cases ; some authorities, 
however, are inclined to look upon the intemperance of 
parents as, at least, a predisposing element, and regard the 
vice of drunkenness as one of the sins of the fathers visited 
upon their offspring. Congenital deficiency of the bile-duct 
is always attended by cirrhosis. Constitutional syphilis 
frequently, and general tuberculosis occasionally, precede it. 
It is not limited to any sex or age, though more frequent in 



AFFECTIONS OF THE LIVER. 405 

boys than girls, and oftener met with between the sixth and 
twelfth years than at an earlier period of life. 

Symptoms. — Both forms are preceded, for a variable time, 
by the evidences of defective nutrition, but, as might be ex- 
pected from the different pathological conditions, the after- 
symptoms are dissimilar. With atrophic cirrhosis the child is 
peevish and restless, sleeps badly at night ; has indigestion, 
flatulence, and costive bowels ; a pale and pasty complexion, 
and dark circles about the eyes. His muscles grow flabby, 
there is general wasting, and the urine is thick with lithates, 
or is very acid and deposits a brick-dust sediment of uric 
acid. After these symptoms have been present for a period 
— usually a long one — pain in the region of the liver and 
ascites are developed. With the ascites there is prominence 
of the abdomen, dilatation of the superficial abdominal veins, 
and, at first, enlargement of both the liver and spleen. Soon 
the liver begins to decrease in size, but the spleen continues 
to enlarge.* Weakness and loss of flesh are progressive ; 
the ascites becomes more marked ; there is oedema of the feet 
and legs ; the skin is sallow, and harsh to the touch ; the 
tongue is coated ; the appetite impaired ; the stomach irrita- 
ble ; the bowels alternately confined and relaxed ; there is 
abdominal pain ; hemorrhoidal swellings are noticeable ; 
hemorrhages occur from the stomach, bowels, nose, and 
gums, and petechial spots appear beneath the skin. 

The course is prolonged and is interrupted by periods ol 
apparent improvement, during which the ascites diminishes 
and the patient is free from discomfort, and in some degree 
recovers health and spirits. 

General dropsy, severe diarrhoea, or hemorrhages indicate 

*If ascites be extreme, it is often difficult to detect the spleen by palpation 
when the patient is in the ordinary dorsal position, or on the right side. In such 
cases, placing the patient upon the hands and knees entirely removes the diffi- 
culty. 



406 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

that the end is near. Sometimes intercurrent inflammation of 
the pleura or lungs is the direct cause of death. 

In hypertrophic cirrhosis, the skin, conjunctivae, and urine 
are deeply stained by bile, and the stools, which vary greatly 
in number and consistency, are clay-colored. The liver and 
spleen are enlarged, but there is no distention of the superfi- 
cial abdominal veins, and no ascites. At times the jaundice 
and enlargement of the liver increase rapidly ; then there is 
moderate fever, with much pain in the right hypochondrium. 
As the end approaches the pulse becomes markedly irregular ; 
the tongue grows dry and brown ; the teeth are covered with 
sordes ; there is complete anorexia, rapid wasting, bleeding 
from the gums, from the stomach, or beneath the skin ; apy- 
rexia, drowsiness, stupor, and, finally, convulsions. The 
course is more rapid than in the former variety, but still pro- 
tracted. Should both forms exist together, there is a combi- 
nation of jaundice, ascites, and distention of the veins in the 
abdominal wall. 

Diagnosis. — The characteristic features of atrophic cirrho- 
sis are diminution in the area of liver dulness, following a tem- 
porary increase in the bulk of the organ ; enlargement of the 
spleen, dilatation of the superficial veins, ascites, hemorrhoids ; 
a dry, earthy skin, and gastro-intestinal hemorrhages, occur- 
ring, without fever, in a child who has a history of prolonged 
ill health, feebleness, and wasting. 

The second and more uncommon variety, while having very 
much the same preliminary history, presents as its distinguish- 
ing marks enlargement of the liver and spleen without ascites ; 
jaundice, with fever ; pain in the hepatic region ; and, subse- 
quently, malignant jaundice, with typhoid symptoms, rapid 
wasting, coma, and convulsions. 

Acute yellow atrophy, which has many of the symptoms of 
the final stage of the biliary cirrhosis, is distinguished by its 
abrupt onset and rapid course, and is rare in children; 



AFFECTIONS OF THE LIVER. 407 

Prognosis. — The result is almost invariably unfavorable, 
and it is only under the most fortunate conditions that even a 
temporary improvement can be obtained. 

Treatment. — Before a diagnosis is established, and while 
the patient is merely suffering from ill-defined symptoms of 
bad health, with imperfect digestion, hygienic and therapeutic 
measures are to be directed to the restoration and preservation 
of the general strength, and to correcting any disorder of the 
organic functions. 

When the hepatic affection declares itself, an alkaline or a 
purely tonic treatment may be adopted. Alkalies are indicated 
when the hepatic and gastro-intestinal symptoms are in excess 
of the wasting and general debility ; tonics, under opposite cir- 
cumstances. In the former case, the following prescription is 
useful : 

R • Sodii bicarb. , 3 ij 

Tr. nucis vom., rr^xviij 

Inf. calumbce, q. s. ad f^iij. M. 

Sig. — Two teaspoonfuls three times daily, for a child of ten years. 

In the latter, Basham's mixture may be employed, or a com- 
bination of iron and quinine, as : 

R . Quininre sulph., , gr. xij 

Tr. ferri chloridi, f ^j 

Syr. zingib., f 3jj 

Aquae, q. s. ad 15 iij. M. 

SlG. — Two teaspoonfuls three times daily. 

Both plans must be followed out steadily and continuously, 
to obtain any beneficial results. In cases of syphilitic origin, 
mercurials or iodide of potassium, in full doses, are indicated. 

To relieve constipation, from two to four fluidounces of 
Hunyadi water should be taken every morning on an empty 
stomach. Diarrhoea can be controlled by subcarbonate of 
bismuth, and hemorrhage by gallic acid or aromatic sulphuric 
acid. 



408 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

It is important to order a liberal diet — milk, eggs, meat, and 
farinaceous foods in full proportion to the capacity of digestion. 
As in other diseases of the liver, the skin must be kept active by 
daily warm baths, and chilling prevented by flannel under- 
clothing. 

If ascites be so great as to impede the action of the dia- 
phragm, paracentesis must be resorted to at once. A fine 
trocar or one of Southey's tubes may be used.* The opera- 
tion should be repeated so soon, and as often, as reaccumula- 
tion renders it necessary. When performed early enough, it 
sometimes has, as in adults, more than a merely palliative 
effect. 

SUPPURATIVE HEPATITIS. 

Abscess of the liver is an extremely uncommon disease in 
children. The lesion may result from traumatism, or may be 
secondary to pylephlebitis originating in the umbilical vein, or 
following appendicitis, suppuration of the mesenteric glands, 
or peritonitis following typhoid fever. It is also due to the 
migration of lumbricoid worms from the intestine into the hepa- 
tic ducts, and is sometimes produced by dysentery ; in many 
cases, however, it is quite impossible to trace the etiology. 

A single abscess or several abscesses may be developed in 
the liver ; the former is the case in traumatism ; the latter, 
when the cause is pyaemia or pylephlebitis. The right lobe is 
the usual seat. 

Symptoms. — In traumatic abscess, the injury is imme- 
diately followed by the superficial evidences of contusion and by 
pain in the hepatic region with the symptoms of perihepatitis. 
These features may disappear or continue until suppuration 
begins. The formation of pus gives rise to rigors, frequency 
of the pulse, night sweats, and fever, the latter often resem- 

* See section on Ascites. 



AFFECTIONS OF THE LIVER. 4O9 

bling the pyrexia of quotidian or tertian intermittents. Jaun- 
dice is present only in exceptional instances. Sometimes the 
general symptoms are very latent, in many cases no suspicion 
of an abscess being entertained until its discovery by manual 
exploration, or by the discharge of pus in various directions, 
and sometimes even not until revealed by post-mortem 
examination. 

The local symptoms, on the contrary, are usually well 
marked, especially when the abscess occupies an accessible 
position in the right lobe of the viscus ; thus there is localized, 
though extensive, enlargement of the involved lobe, and upon 
this enlargement there is an ill-defined, oblong tumor extend- 
ing beyond the level of the abdomen. The skin covering 
this tumor is at first slightly oedematous, but perfectly mova- 
ble and normal in color and temperature. From day to day, 
as the tumor becomes more circumscribed and approaches the 
surface, the hepatic enlargement increases ; and conjointly 
with the appearance of fluctuation the oedema disappears, the 
skin becomes dusky-red in hue, hotter than the surrounding 
integument, and adherent. There is also tenderness on 
pressure ; pain excited by deep inspiration or any jarring 
movement, and a peculiar bending forward of the body in 
walking. The situation of the pain is not constant ; it may 
be in the epigastrium, in the umbilical region, in the lower 
segment of the abdomen, or, at times, in the right shoulder. 
Again, after opening such an abscess, all these symptoms 
subside, and there is puckering of the skin and rapid reduc- 
tion in the size of the liver ; its projecting margin remaining 
semicircular, smooth, and well defined. Finally, there is 
slight contraction of the affected lobe. 

There are two other points of importance : viz., the detec- 
tion, by palpation, of a smooth edge of dense tissue bordering 
the area of fluctuation, which gives the impression that the 
fluid is contained in a cup-shaped cavity in a solid organ ; and 



4IO DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

the characters of the fluid, which is more puriform than 
purulent, yellow or red in color, and shows, under the micro- 
scope, numerous minute granules, fat globules, — free or in 
large cells, — leucocytes, and abundant minute rhombic or 
clustered acicular crystals of bilirubin. 

If the abscess be seated at the convexity of the liver, there 
is usually cough and dyspnoea, or the symptoms of pleuritis 
may develop, inflammation extending through the diaphragm 
or pus escaping into the pleural cavity. When the lesion 
occupies the lower portion of the organ, there is obstinate 
vomiting and other indications of gastro-intestinal sympathy. 

Multiple or pyaemic abscesses, being produced by infection 
from some point in the portal area, are preceded by a history 
of suppuration. Therefore, active abdominal symptoms are 
present, before jaundice, hepatic pain and enlargement, chills, 
intermittent temperature, and sweating indicate involvement 
of the liver. With the jaundice, features of the typhoid state 
appear : the tongue becomes dry and brown ; sordes collect 
upon the teeth ; there is diarrhoea, subsultus, low, muttering 
delirium, or stupor ; the urine grows scanty, is high-colored 
from excess of bile pigment, and contains albumin, blood, and 
epithelial and granular casts. Death occurs from convulsions 
or exhaustion. 

Diagnosis. — The recognition of hepatic suppuration is 
always difficult unless the abscess is large, so situated that it 
can be readily palpated through the abdominal wall, or unless 
" liver pus " can be obtained by aspiration. The characteristic 
features are the presence of one of the known causal factors, 
and the development of chills, intermittent fever, sweating, 
and a painful tender enlargement of the liver, presenting a 
localized area of extreme elasticity or of actual fluctuation. 

Hepatic abscess is frequently confounded with malarial 
fever. From this it may be distinguished by its non-response 
to the administration of quinine, and by the absence of 



AFFECTIONS OF THE LIVER. 4 1 I 

marked splenic enlargement and of malarial organisms in the 
blood. 

Certain cases closely resemble empyema. Here the points 
of distinction are that in hepatic abscess the upper margin of 
dulness is usually higher in front than behind and that the 
lung is everywhere in contact with the abscess, whereas in 
empyema it is compressed and forced toward the spine and 
upper part of the thoracic cavity. 

When, as is often the case, it is necessary to resort to 
aspiration to establish the diagnosis, the patient must be an- 
aesthetized and the needle. inserted — several times, if required 
— into any tender, yielding spots in the portion of the liver 
projecting below the costal border and into the seventh right 
intercostal space in the axillary line, or at the same level in 
front or behind if the area of dulness extends above these 
points.- Such puncture is usually harmless, though it may 
be attended by considerable bleeding so long as the needle 
remains in the organ. 

Prognosis. — In multiple abscess the outlook is very grave, 
the ordinary termination being in death. The same may be 
said of a single abscess situated beneath the diaphragm on 
the convexity of the right lobe. On the other hand, a single 
abscess, if superficial and so placed that it can be readily 
reached by the aspirating needle or knife, offers a much more 
favorable prognosis. 

Treatment. — The general management of circumscribed 
hepatitis, prior to the formation of pus, — if the symptoms be 
such as to lead to a diagnosis at this time, — simply requires 
careful regulation of the diet, rest, and attention to the various 
functions of the body, particularly that of the bowels ; for 
even if the existence of inflammation be ascertained, it is 
hardly probable that anything can be done to prevent 
suppuration. 

When an abscess has formed, the treatment is purely 



412 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

surgical. A few cases have recovered after aspiration, but free 
incision and subsequent drainage are alone to be depended upon. 
After operation strict rest should be enjoined, and tonic and 
supporting measures employed. Subsequently, nutritious 
diet and exercise in the open air, the latter adapted to the 
strength of the patient, are much more important than mere 
medication. 

Tuberculosis of the liver is sometimes associated with 
tuberculous peritonitis, and is commonly encountered at the 
autopsies of children who have succumbed to acute general 
tuberculosis. In such cases the liver is anaemic, yellowish, 
and somewhat enlarged. Semi-transparent granules (miliary 
tubercles) are seen upon the capsule and detected by the 
microscope in the connective tissue that surrounds the 
branches of the finer bile-ducts. The tubercles may attain 
considerable size in chronic cases, and undergo rapid softening, 
with the formation of abscesses containing bile-stained pus ; 
these vary in size from that of a pea to that of a marble, 
and, at times, are very numerous. There are no definite symp- 
toms and a diagnosis is hardly possible without post-mortem 
section. 

Hydatid disease and cancer are so infrequent in childhood, 
and when they do occur present so nearly the symptoms of 
the same conditions in adults, that it is unnecessary to devote 
space to their consideration. 



CHAPTER VI. 
AFFECTIONS OF THE PERITONEUM. 

PERITONITIS. 

Children, like adults, are subject to attacks of inflammation 
of the peritoneum. These may be primary or secondary in 
origin, acute or chronic in course, and general or local in 
distribution. 

The affection occurs at any age from birth to puberty, and 
there are indisputable evidences on record of its developing 
during the later months of intra-uterine life. The primary or 
essential form is almost uniformly acute and general. Secon- 
dary peritonitis, on the contrary, may be either general or 
local, the inflammation often beginning in a limited area and 
gradually extending over the whole surface. It is also more 
common than the primary variety, and, while often acute, 
more frequently runs a chronic course. 

Morbid Anatomy. — In acute general peritonitis the blood- 
vessels of the subserous tissue of the peritoneum are engorged 
with blood, and the membrane is reddened, either generally or 
in patches, mottled by isolated spots of ecchymosis, and 
opaque and thickened. Serum, sometimes clear, sometimes 
mixed with pus and flakes of fibrin, fills the abdominal cavity ; 
or, again, the effusion may be purulent ; in either case, it is 
most abundant in the pelvis and between the mesenteric 
folds. 

Acute local peritonitis occasions connective-tissue hyper- 
plasia, omental and intestinal adhesions, and, at times, local- 
ized suppuration. 

413 



4H DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Chronic general peritonitis gives rise to a sero-fibrinous 
exudate ; this may be sufficiently abundant to appear as a 
thick membrane, and in time may undergo fatty, caseous, or 
calcareous degeneration. 

Chronic local peritonitis results in the formation of circum- 
scribed adhesions, membranous exudations of limited extent, 
and sacculated collections of pus. 

Etiology. — Fcetal peritonitis is caused by syphilis or some 
specific infection of the mother. During the first few days ol 
life it may be due to inflammation, suppuration, or gangrene 
of the umbilicus ; to congenital occlusion of the anus ; or to 
infection from a mother ill with puerperal fever. Later in 
childhood, primary peritonitis arises from blows upon, or other 
injuries to, the abdomen, from severe burns, and sometimes 
from sudden chilling of the body after violent exercise. The 
secondary form most frequently results from the escape of faecal 
matter into the abdominal cavity through a perforation of the 
intestine — the so-called perforative peritonitis. Appendicitis 
is the condition in which this accident usually occurs, intes- 
tinal perforation during typhoid fever being rare in childhood. 
It may also occur during the course of one of the infectious 
diseases, pneumonia and scarlatina especially. Finally, it may 
be occasioned by extension of inflammation from some one of 
the abdominal viscera, or from the pleura ; in the last instance 
there may be an element of sepsis. 

The bacteria commonly associated with peritonitis in early 
life are : the streptococcus, particularly in the newborn ; the 
pneumococcus in cases associated with pneumonia or empy- 
ema ; and the bacterium coli commune in those due to intes- 
tinal perforation. 

Chronic peritonitis sometimes follows an acute attack, but 
is most often an attendant of tuberculosis and presents the 
characters of chronicity from the outset. 

Symptoms. — In primary peritonitis, and in other cases ot 



AFFECTIONS OF THE PERITONEUM. 415 

the acute general disease not due to perforation or sepsis, the 
attack begins with more or less rigor, abdominal pain, and 
vomiting. The pain is stinging or lancinating in character, 
and is limited, at first, to one flank, to the supra-pubic region, 
or the neighborhood of the umbilicus, but soon becomes 
general ; it is increased by pressure or by any act calling the 
abdominal muscles into play, as deep breathing, sneezing, 
coughing, and vomiting. The vomiting is frequent and very 
violent, producing so much distress and fatigue that after each 
effort the patient falls back on the pillow with pale, haggard, 
and sweat-bedewed face. The material rejected consists, in the 
beginning, of partially digested food ; later, of bile-stained 
mucus. 

Fever quickly follows the shivering, and as soon as inflam- 
mation is fully established^ the axillary temperature may reach 
104 F., although the usual range is from ioi° to 102 . 
With the pyrexia there is a frequent, small, wiry pulse, and 
the breathing assumes the superior costal type ; in some 
cases (where there is a large effusion) growing hurried and diffi- 
cult. The child ceases to move his legs, or takes to bed 
early and lies immovably upon his back, with the knees 
drawn up. The face is pale and anxious, the nose sharp and 
the nostrils thin and expanded. The abdomen is distended 
and passive, so far as respiratory movements are concerned ; 
palpation yields a certain sense of resistance, sometimes de- 
velops fluctuation,* and always excites intense pain ; percus- 
sion elicits tympany over the upper anterior portion of the 
belly and dulness over the dependent parts, and on ausculta- 
tion, friction sounds may be heard when there is a fibrinous 
exudation. 



* When fluctuation is indistinct, Duparcque recommends that the child be 
placed on one side for a few moments, so that the whole quantity of fluid may- 
gravitate to the depending flank ; then quickly turned upon the back, when dul- 
ness and temporary fluctuation will be found at the site of accumulation. 



4l6 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

The tongue is pointed, red at the tip and edges, and cov- 
ered in the centre with a dry, moderately heavy, brown-white 
fur. There is anorexia and increased thirst. Constipation is 
the rule if the intestinal peritoneum be involved ; then, too, 
there are frequent attacks of severe griping pain ; on the 
other hand, there may be diarrhoea, with watery evacuations, 
if the inflammation be attended by oedema of the submucosa 
with transudation of serum into the bowel. 

The urine is high-colored and somewhat reduced in quan- 
tity, and, while ordinarily passed with freedom, is retained 
when the serous coat of the bladder is involved in the inflam- 
mation. 

Sleep is disturbed and restless ; in infants there may be 
convulsions ; in older children, delirium, though the mind 
often remains clear. 

During the course of the attack, which usually extends 
over a period of seven days, the strength steadily fails ; there 
is considerable loss of flesh, and the symptoms present at 
the onset continue unabated and unchanged. As death ap- 
proaches vomiting usually stops, but the other symptoms 
become more and more grave. The patient lies in an 
apathetic condition, with sunken eyes and half-closed lids ; his 
face is drawn and either pale or cyanosed ; the tongue is dry, 
brown, and pointed ; there is marked tympanites, and the 
pulse is extremely small and frequent. 

Occasionally this variety of acute peritonitis ends in recov- 
ery, the exuded fluid being either reabsorbed or spontane- 
ously evacuated through the umbilicus or abdominal wall.* 
In the first instance, the symptoms subside gradually ; in the 
second, rapidly ; though in both the course is protracted, the 
fistulous openings left after the discharge of pus rarely closing 
under four or five weeks. 

* M. Gauderon mentions ten such cases, eight of which recovered. 



AFFECTIONS OF THE PERITONEUM. 417 

Perforative peritonitis requires separate description, since it 
has a set of symptoms entirely its own. It is the most com- 
mon form of the disease in children, and in the majority of 
cases, as already stated, results from rupture of the vermiform 
appendix ; perforation of typhoid or tuberculous ulcers being 
exceptional in this class of patients. 

The attack begins suddenly, with intense pain in the abdo- 
men, quickly followed by profound collapse. The face soon 
becomes pale and haggard ; the eyes are deeply sunken, and 
the hands and feet cold, though the body heat is increased, 
the rectal temperature ranging to 103 or 104 . Other 
features are great thirst, occasional vomiting, a dry, red, and 
pointed tongue ; locked bowels ; a rapid, small, thready 
pulse ; thoracic respiration, often hurried and difficult, and 
suppression of urine. From the beginning the belly is greatly 
distended by gas escaping from the intestine ; the abdominal 
respiratory movements cease ; palpation is very painful, and 
percussion yields a uniformly drum- like tympany that extends 
high up under the ribs, and completely masks the liver dul- 
ness. Death almost invariably takes place either on the third 
or fourth day of illness, and is usually preceded by a few 
hours' freedom from suffering. 

While this is the ordinary course of perforative peritonitis, 
it happens sometimes that the shock is so great that the pa- 
tient neither feels pain nor complains of tenderness when the 
abdomen is touched, and there is a general latency in the 
symptoms. Again, extravasation being limited by preformed 
adhesions, the inflammatory action is circumscribed, and the 
resulting abscess, by pointing and discharging through the 
abdominal wall or into the intestine, may either end in recov- 
er} 7 ", or in the production of a permanent faecal fistula. 

In septic peritonitis the symptoms are either inherently 
latent, or are masked by the collapse that follows the onset 
of a new inflammation in a patient already debilitated by dis- 
35 



41 8 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

ease. There is usually rapid prostration, restlessness, and 
delirium, with a tendency to stupor ; a pale, anxious face ; 
swollen belly ; persistent watery diarrhoea ; a frequent, wiry 
pulse, and quick, costal breathing. Pain, tenderness, tension 
of the abdominal walls, dulness on percussion and fluctuation 
may be entirely absent. Without care, such attacks are 
readily overlooked. 

Should peritoneal inflammation become chronic the pain 
lessens and is more paroxysmal in character ; the fever is re- 
mittent, with evening exacerbations ; constipation alternates 
with diarrhoea ; there is great emaciation, and death occurs 
from exhaustion. However, on account of the usual tuber- 
culous origin, the symptoms of this form will be more appro- 
priately studied in the following section under the head of 
"tuberculous peritonitis." 

Local peritonitis is almost uniformly secondary, that attend- 
ing inflammation of the caecum and vermiform appendix being 
the most common in children. 

Diagnosis. — An immovable dorsal decubitus ; a pale, hag- 
gard face ; a frequent wiry pulse ; distention, pain, and ten- 
derness of the belly ; and inactivity of the abdominal muscles 
in respiration, suffice to render the diagnosis of acute general 
peritonitis easy. Intense pain, sudden collapse, and rapid and 
extreme meteorism characterize the perforative variety. 

In colic there is constipation and vomiting, with severe 
pain ; but between the paroxysms there is no abdominal ten- 
derness, and the pulse is never so rapid, small, and wiry, nor 
is there the fear of movement so noticeable in peritonitis. 

Rheumatism of the abdominal muscles is attended by ten- 
derness on pressure ; distressed facial expression ; dorsal 
decubitus with knees drawn up, and constipation, and thus 
simulates peritonitis ; but the face is never haggard, there is 
no vomiting nor hiccough, nor distention of the belly, neither 
is tenderness extreme. The pulse is soft, compressible, and 



AFFECTIONS OF THE PERITONEUM. 419 

only moderately frequent ; the temperature is nearly normal, 
and the urine is scanty, high-colored, acid, and scalding. 

It is important to remember that constipation is the rule in 
peritonitis when the inflammation involves and paralyzes the 
muscular coat of the bowel ; diarrhoea, when it spreads through 
the muscular coat to the mucous membrane. 

The great difficulty in diagnosis is experienced with latent 
peritonitis, whether septic or due to other causes. Suspicion 
of its existence may be entertained when, in the course of 
any predisposing disease, the patient suddenly grows pale and 
haggard, and has a full belly, with a tendency on the part of 
the abdominal muscles to become rigid on palpation. Rest- 
lessness, delirium and stupor, a change in the type of respira- 
tion and in the character of the pulse, all strengthen the sus- 
picion. Under these circumstances it is well to practice 
Duparcque's method for detecting the presence of fluid, and 
this, if successful, leaves no further doubt. 

In the words of Eustace Smith : " In cases of chronic em- 
pyema we should always be on the watch for the occurrence 
of peritonitis. If the child, after a period of improvement, 
ceases all at once to gain ground, and begins to look pale and 
distressed, with an elevated temperature, a more or less dis- 
tended belly, and a rapid, wiry pulse, we are justified in sus- 
pecting peritonitis, although there be no tension, tenderness, 
or other sign connected with the abdomen to give support to 
this opinion." 

Prognosis. — This must always be most grave. In the 
newborn and in infancy death is the almost invariable result. 
Perforative peritonitis also is very fatal. The primary variety, 
when due to cold, exceptionally ends in recovery, and so, too, 
does the partial form. 

Treatment. — Absolute rest in bed and quiet surroundings 
are essential. Hot applications, in the form of light flaxseed 
poultices and of turpentine stupes, should be made to the sur- 



420 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

face of the belly ; or, if these fail to give relief, cloths wrung 
out of ice-water may be applied ; they must be frequently 
changed, to secure the constant action of cold. Leeching is 
sometimes of great service in subduing pain, but it is only to 
be employed with robust subjects and in an early stage of the 
attack. 

Of drugs, opium alone can be relied upon. It may be ex- 
hibited by the mouth, the rectum, or subcutaneously, and can 
safely be pushed to the point of producing drowsiness, with 
decided contraction of the pupils, provided ease from suffering 
be not attained before. For a child of six years, three drops 
of laudanum every two hours, by the mouth or rectum ; and, 
by hypodermic injection, one-eighteenth of a grain of sulphate 
of morphine, repeated as required, are the average commenc- 
ing doses. 

At the very outset of the attack a saline cathartic may be 
employed, but under no other circumstances is a purge to be 
given. Should constipation be obstinate, and the indications 
urgent to unload the bowels, a simple enema may be employed. 
It is a good rule, however, to interfere as little as possible in 
this way. 

The patient's strength must be sustained by concentrated 
liquid food in small quantities and at short intervals. Three 
fluidounces of peptonized milk and from two to four fluid- 
drachms of raw-beef juice, alternating, every two hours, with 
the occasional substitution of the yolk of a soft-boiled egg 
for one or the other, would be a proper diet for a child of six 
years ; stimulants are also necessary, and so soon as there is 
evidence of failing strength a teaspoonful of good whiskey 
must be added to each portion of milk. Bits of ice may 
be allowed from time to time to allay thirst and quiet the 
stomach. 

Should the inflammation subside, the opium is to be gradu- 
ally withdrawn and its place supplied by sorbefacients and 



AFFECTIONS OF THE PERITONEUM. 42 1 

tonics ; at first mercuiy in alternate doses, or iodide of potas- 
sium, with quinine ; and, later, syrup of the iodide of iron. 
At the same time, the hot or cold application being removed, 
a weak mercurial ointment should be rubbed into the skin of 
the belly once or twice daily ; for example : 

R. Ung. hydrargyri, 

Ung. belladonnse, aa ^ij 

Adipis, . . . : ^iv. M. 

SiG. — Use locally as directed. 

A most important point is to make no change in the diet, 
except, perhaps, to increase gradually the quantity of liquid 
food, until convalescence is fully established. Operation is 
rarely to be considered in acute peritonitis in children, except 
in cases due to perforation, and in these every form of treat- 
ment is of little avail. When the active stage has passed and 
pus has formed, surgical interference is always demanded. 



TUBERCULOUS PERITONITIS. 

As a rule, peritonitis due to the presence of tubercle in the 
abdominal cavity runs a chronic course, and is associated with 
tuberculosis of some other organ of the body — of the brain or' 
lungs, for instance ; less frequently it occurs as an isolated 
affection. Acute tuberculous peritonitis is not unknown ; it is 
detected with difficulty during life, and is invariably an ele- 
ment of general tuberculosis. The disease is quite common 
after the age of seven years, but is rare in earlier childhood 
and in infancy. 

Morbid Anatomy. — Tuberculous peritonitis occurs in sev- 
eral distinct forms : 

(a) Miliary Tuberculosis. — The peritoneum, especially in in- 
fants, may be involved in acute or subacute general miliary 
tuberculosis ; under these circumstances miliary tubercles are 



422 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

deposited, generally diffusely, over the membrane, giving rise 
to little inflammation and no special symptoms. 

{&) Miliary Tuberculosis zvith Ascites. — Here miliary tuber- 
cles are deposited discretely or in large groups and produce 
varying grades of inflammation. The serous membrane is 
congested and there is an exudate of fibrin in small quantities 
and of serum or sero-purulent or bloody fluid in great, though 
not excessive, bulk ; this fluid is free in the general peritoneal 
cavity in acute cases, sometimes sacculated in those that are 
chronic. 

(c) The Fibrous Form. — In this variety, which is the most 
chronic, the products of tuberculous inflammation undergo 
transformation into fibrous tissue, nature's effort for health res- 
toration. The outcome of the process is the formation of 
more or less extensive organized adhesions between the intes- 
tinal loops and between these and the abdominal wall. As- 
cites may or may not be present. If the former, the fluid may 
be serous or sero-purulent, and either free or sacculated. 

(d) The Ulcerative Form. — This form stands midway be- 
tween b and c in point of chronicity, and is frequently encoun- 
tered during childhood. It is usually general, but may be 
localized. There is an extensive fibrinous exudate, causing 
the coils of the intestines to adhere to one another and to the 
viscera and abdominal walls. In this the tuberculous deposit 
appears as small, yellow nodules and large caseous masses, 
which have a tendency to undergo softening. The same 
caseous deposits are found in the omentum and mesentery, 
which are much thickened. The adhesions also form sacks 
containing serum or more often purulent matter. Tuberculous 
deposits are present in the intestinal peritoneum, and infiltrate 
the intestinal walls, leading to perforation or to fistulous com- 
munication between the coils of the gut. A similar infiltra- 
tion may affect the abdominal walls and be attended by cellu- 
litis and suppuration, the abscess opening externally, gene- 



AFFECTIONS OF THE PERITONEUM. 423 

rally in the umbilical region. This form of the disease may 
originate as such, or may follow the miliary or fibrous forms, 
and is always associated with tuberculosis, usually advanced, 
in the lungs or other organs of the body. 

Etiology. — The factors leading to peritoneal tuberculosis 
are identical with those producing other tuberculous affections. 
The age at which the disease is most prone to occur has 
already been mentioned. Male children seem to suffer more 
frequently than those of the opposite sex. 

Symptoms. — The features of tuberculous peritonitis vary 
considerably with the form the disease assumes, but the fol- 
lowing description portrays the general clinical picture. The 
onset is slow and insidious, and the physician is apt to have 
his attention diverted from the abdomen by more striking 
manifestations of tuberculosis in the lungs or other organs. 
Unless such features be present and precedent, there is but 
little evidence of failing health in the beginning, and the 
first symptom to attract notice is an abnormal prominence 
of the belly. The patient gradually grows dull and listless, looks 
ill, and, on account of abdominal tenderness and the pain pro- 
duced by jarring, becomes slow and guarded in his movements. 

Often after the disease is fully developed the child " keeps 
about," but the face is drawn and wears an expression of 
anxiety and suffering ; the frame slowly wastes, and the skin 
becomes dry and harsh and loses its healthy hue. Com- 
plaints are made of tenderness and griping pains in the abdo- 
men, and the little sufferer takes very characteristic precau- 
tions to lessen his ills by steadying his belly with his hands 
in walking, and by moving downstairs backward so as to pass 
from step to step on his toes, to avoid jolting. The symp- 
toms denoting disturbance in the functions of the gastro- 
intestinal tract are inconstant ; the tongue either shows little 
alteration or is lightly frosted or more pointed and red than 
natural ; nausea and vomiting may be entirely absent, and 



424 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

are never so persistent and severe as in simple peritonitis ; 
the appetite often remains unimpaired, and the bowels are 
alternately relaxed and confined. On the other hand, the 
signs to be detected by abdominal exploration are very con- 
stant and characteristic. The belly is oval in shape and 
somewhat irregularly distended, the greatest enlargement 
occupying the epigastric and umbilical regions ; the natural 
folds and furrows are obliterated ; the superficial veins are 
prominent ; and the integument has a smooth, shining appear- 
ance, as if smeared with oil. When the hand is applied to 
the surface, the recti muscles become tense, in an involuntary 
effort to protect the tender parts beneath ; some portions of 
the abdomen feel soft and flaccid ; in others, firm masses are 
perceptible to the touch ; tenderness on pressure is universal, 
though most marked over the firm masses. Palpation also 
reveals fluctuation ; this is usually indistinct, though occasion- 
ally, when enlarged glands or cheesy masses exert pressure 
on the portal vein, there is a large collection of fluid in the 
peritoneal cavity, and the fluctuation wave is readily elicited 
and very distinct. The edge of the right lobe of the liver 
can often be felt extending half an inch or more beyond the 
right costal border. On percussion, tympany will be elicited 
over the flaccid portions of the abdomen ; dulness over the 
firm masses and flatness over the flanks — in the recumbent 
position — while, if the patient be rolled to one side, the note 
on the flank turned uppermost becomes tympanitic. 

The respiratory movements are somewhat increased in fre- 
quency and thoracic in type ; the pulse is quickened and 
feeble in proportion to the general weakness ; the axillary 
temperature ranges from gS° F. in the morning to ioi° F. in 
the evening ; and there is dysuria with high-colored, but 
otherwise unaltered, urine. Sometimes, with a large collec- 
tion of fluid in the peritoneum, there is oedema of the feet and 
legs ; then, too, the urine may be slightly albuminous. 



AFFECTIONS OF THE PERITONEUM. 425 

In time the patient is forced to go to bed, where he lies on 
his back, or partially turned on one side, with his legs drawn 
up ; this position is rigidly maintained, for every movement is 
painful. Now the wasting is rapid ; the face wears a haggard 
expression ; the cheeks and temples are hollow, and the skin 
becomes inelastic and dotted with purpuric spots. The 
tongue is dry, heavily coated, or red and smooth ; the appetite 
fails and there is urgent thirst. The bowels are in one of two 
conditions : relaxed, with watery, offensive stools, containing 
flaky matter and small black clots of blood, when there is 
tuberculous ulceration ; obstinately confined, when the intes- 
tines are pressed upon, or obstructed by adhesions. In the 
latter case the belly becomes greatly distended, and there are 
frequent attacks of severe colicky pain. Under other circum- 
stances, however, the size of the belly may diminish, and 
then hard, tender lumps are felt in contact with the abdominal 
wall. The pulse is more frequent and feeble ; the evening 
temperature ranges as high as 103 and 104 , and night 
sweats are common. 

The course of the disease is not uniformly progressive, 
being interrupted by remissions and exacerbations. Dur- 
ing the former the tenderness and distention of the ab- 
domen diminish, the appetite returns, nutrition improves, and 
false hopes arise of rapid recovery. Death occurs after a 
lapse of time varying from several months to a year or 
more. 

Sometimes before death an abscess forms, and pus is dis- 
charged through the abdominal wall in the neighborhood of 
the umbilicus ; in other cases the intestines may be perforated 
from without, but this complication scarcely hastens the fatal 
termination, for extravasation is limited by adhesions between 
the knuckles of the intestines. Such complications as tuber- 
culosis of the lungs and cerebral meninges, however, certainly 
hasten death. 
36 



426 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Acute tuberculous peritonitis always occurs as an element ot 
disseminated tuberculosis, and presents the general features 
of that condition ; usually there are no local manifestations 
other than abdominal fulness and slight pain — symptoms 
sufficiently common in children to be altogether indefinite. 
The course of these acute attacks is measured in little more 
than a week. 

Diagnosis. — Ordinarily the formation of a correct opinion 
is not difficult. The distinctive features are the irregular dis- 
tention of the abdomen ; the smooth, shiny appearance of the 
investing skin ; tenderness ; unequal resistance to the touch 
in different positions, and indistinct fluctuation, combined with 
alterations in the temperature ; impairment of nutrition ; an 
insidious onset ; a family record of tuberculosis ; the presence 
of the tuberculous diathesis, and the existence of symptoms of 
tuberculous deposit in some other organs of the body. In 
doubtful cases, where there is little distention or tenderness, 
and fluctuation is absent, it is well to try the effect of a sud- 
den jar ; this may be done by directing the child to jump 
from a low chair to the floor. Free fluctuation is to be 
regarded as a point in the negative. 

Many children have prominent bellies and suffer severely 
from abdominal pain, both due to the accumulation of flatus 
in the intestines, the consequence of a chronic catarrh' of the 
mucous lining. These patients, though pale and flabby, are 
but little wasted, and express in their faces no trace of severe 
illness ; they are lively in action ; their temperature is normal ; 
there is no tenderness or involuntary contraction of the recti 
muscles on palpation ; the abdominal distention disappears 
spontaneously at times, and subsides entirely when a non- 
farinaceous diet is ordered. There can be no greater mistake 
than that of attributing every instance of abdominal disten- 
tion to tuberculosis. 

As already stated, the diagnosis of the rare acute form is 



AFFECTIONS OF THE PERITONEUM. 427 

very difficult, and is often made only at the postmortem table. 
Typhoid fever is the disease most likely to be confounded 
with it, but the absence of rash and splenic enlargement, and 
the difference in the degree and course of the fever should 
prevent error. 

Prognosis. — This depends upon the form the disease 
assumes. The ulcerative form is always fatal ; in the ascitic 
and. fibrous varieties the outlook is much more favorable, 
especially since laparotomy has been generally recognized as 
the proper method of treatment. 

Treatment. — While little is to be expected from thera- 
peutic measures, the physician's ambition will be to obtain a 
favorable result if he can. To accomplish this end it is neces- 
sary, first, to keep the child at perfect rest in bed ; and, 
second, to select a diet that will meet the capacity for diges- 
tion, excluding as nearly as may be the farinaceous foods so 
prone to cause acidity and flatulence, with their attendant 
suffering. The following is a sample diet list for a patient of 
seven years ; 

For breakfast, at 7.30 a. m. — The yolk of a soft-boiled egg, 
a slice of well-toasted bread lightly buttered, and a tumbler- 
ful (f Sviij) of warm milk. 

For luncheon, at 12 m. — The soft parts of a dozen oysters 
or a bit of fish, or a bowl (fsyj) of good meat-broth, with a 
biscuit. 

For dinner, at 3 p. m. — Two to four tablespoonfuls of minced 
mutton or chicken, one or two thin slices of stale buttered 
bread, eight tablespoonfuls of rice and milk or junket. 

For supper, at 7 p. m. — Two slices of milk-toast and a 
tumblerful of warm milk. 

Such a list can only be used in the earlier stages of the dis- 
ease ; later, when the appetite fails, it is necessary to resort 
to liquid food, milk, and meat-broths, administered in small 
quantities at short intervals. 



428 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Stimulants — and whiskey is the best — are required from 
the beginning, and must be given in increasing quantities as 
the strength fails. 

Of drugs, opium, quinine, and syrup of the iodide of iron 
with cod-liver oil, when the stomach will bear them, are the 
most useful. Opium must be given sufficiently freely to re- 
lieve pain, and quinine in doses large enough to maintain the 
flagging forces. Constipation is to be remedied only by simple 
enemata, while excessive diarrhoea may be checked by full 
doses of bismuth combined with ipecacuanha and opium, as : 

R . Pulv. ipecacuanhse comp., gr. xxiv 

Bismuth, subcarb., 3J 

Pulv. aromat., gr. xij. 

M. et ft. chart. No. xij. 

SlG. — One powder every two or three hours for a child of seven years. 

A good formula for the same purpose is : 

R . Ext. hsematoxyli, gr. xxx 

Tr. opii deod., TT^xxiv 

Vin. ipecacuanha, . TT\,xxxvj 

Mist, cretae, q. s. ad f^iij. M. 

Sig. — Two teaspoonfuls every three hours. 

Externally, light flaxseed poultices are useful in relieving 
pain. Sometimes even the lightest poultice is uncomfortable, 
then the abdomen may be anointed once daily with : 

R . Ext. belladonnse, g ij 

Glycerini, f ^ vj ; M. 

and covered with a thick layer of cotton batting. While these 
methods are useful in maintaining strength and relieving 
symptoms, the only treatment that carries any promise of 
radical curative results is surgical interference in properly 
selected cases. 

ASCITES. 

The collection of a quantity of transparent serum in the sack 
of the peritoneum is not of very common occurrence during 



AFFECTIONS OF THE PERITONEUM. 429 

childhood. The condition is, probably, always secondary, and 
must be regarded rather as a symptom than a disease proper ; 
it is of sufficient import to warrant a brief separate considera- 
tion. 

Etiology. — Ascites is produced by simple or tuberculous 
inflammation of the peritoneum ; it also depends upon ob- 
struction to the return of venous blood, due to diseases of the 
liver or heart ; to enlargement of the mesenteric glands, and, 
occasionally, to disease of the lungs ; again, it may be the re- 
sult of a general hydraemic state of the blood, attending 
affections of the kidneys and anaemia. It is sometimes impos- 
sible to decide upon the pre-existing lesion. 

Symptoms. — In a well-developed case the abdomen is dis- 
tended and globular, the exact shape depending upon the posi- 
tion of the patient, being broader in the recumbent than in the 
erect posture, as then the fluid tends to spread and collect in 
the flanks. The integument is smooth and shining ; the 
superficial veins are very distinct, and the normal depression 
at the umbilicus is either effaced or there is a projection at this 
point. There is a sense of fulness, with moderate resistance, 
but no tenderness on palpation ; and if a hand be placed on 
either side of the belly, and a sharp tap given with one of the 
fingers, a distinct impulse — fluctuation wave — is felt by the 
other hand ; this is not interrupted, as in the case of flatulent 
distention, by pressure, made by an assistant, on the median 
line. While the child lies upon its back, percussion is tym- 
panitic over the upper anterior parts of the belly, where the 
intestines float free, and dull elsewhere ; a change in position 
alters the relation of the areas of tympany and dulness, and 
the extent of the latter depends entirely upon the amount of 
fluid present. 

Pain is not a prominent symptom ; if present, it is paroxys- 
mal, and has the griping character of the colic of intestinal in- 
digestion. Such attacks are often attended or followed by 



430 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

moderate diarrhoea ; in the intervals the bowels may be con- 
fined. Should the effusion be large, the mere weight of the 
fluid causes discomfort ; then, too, respiration is embarrassed, 
even to the extent of orthopncea ; micturition is painful ; the 
urine is scanty, high-colored, and albuminous ; and there may 
be oedema of the genitalia and legs, resulting solely from 
pressure. 

Cases having an obscure etiology furnish a few additional 
features ; there are no constant or characteristic alterations of 
the tongue, appetite, appearance of the skin, or temperature ; 
for these, with other rational symptoms, depend upon the 
determining disease. 

When due to inflammation of the peritoneum, the amount 
of effusion is usually moderate ; the abdomen is tense and 
tender ; the temperature is usually elevated, and the general 
symptoms of acute or chronic peritonitis are more or less 
marked. 

In hepatic disease, especially cirrhosis, the effusion is great ; 
the superficial abdominal veins are very prominent ; the 
hemorrhoidal veins are distended ; the spleen is often enlarged ; 
the digestive functions are impaired, and the general integu- 
ment has a sallow hue or is decidedly jaundiced. 

Cardiac disease causes anasarca and hydrothorax as well as 
ascites, and these conditions are apt to be associated ; the face 
is livid ; the lips and finger-tips blue; the jugular veins are 
distended and pulsating ; there is dyspnoea, and a scanty, 
albuminous urine, with the physical signs of heart lesion. 

Diagnosis. — There is little difficulty in detecting ascites, 
unless the effusion be so small that it sinks away into the 
pelvis or between the folds of the intestine beyond the reach 
of the examiner's hand. Under these circumstances it is well 
to try Duparcque's method (see page 415) of increasing 
the distinctness of fluctuation, or to put in practice another 
plan for the same purpose : namely, placing the patient on the 



AFFECTIONS OF THE PERITONEUM. 43 I 

hands and knees so that the fluid may gravitate to the most 
dependent portion of the abdomen — now the neighborhood 
of the umbilicus — and come within the range of palpation. 

A large belly, produced by flatulent distention of the intes- 
tines, may yield indistinct fluctuation, the palpation stroke 
being transmitted through the bowels ; but the imperfect wave 
is readily interrupted by pressure in the median line, and the 
results of percussion are quite different from those obtained in 
ascites. 

The collection of a large quantity of fluid in the pelvis of 
one or other kidney — hydronephrosis — is attended by abdomi- 
nal distention, fluctuation, and percussion dulness. The en- 
largement, however, is more noticeable on the side of the 
affected kidney ; here, also, there is more resistance and 
greater dulness, the opposite flank being often tympanitic ; 
changes of position have little effect in altering the percussion 
sounds, the umbilicus rarely protrudes, a kidney -shaped out- 
line can often be detected, and tapping liberates a liquid 
charged with urea. 

The prognosis depends chiefly upon the nature of the 
originating disease. When this cannot be discovered, the fore- 
cast must be based upon the general strength and nutrition, 
the condition of the skin, the temperature, and the character 
of the urine. If the strength be moderately preserved, the 
appetite and digestion fairly good, the skin natural in texture 
and color, the temperature normal, and the urine free and non- 
albuminous, the prognosis for an ultimate recovery is good, 
irrespective of the amount of effusion. 

Treatment. — This must, in the main, be regulated by a 
consideration of the primary disease. Cases of obscure origin, 
as well as those depending upon anaemia or disease of the 
liver, are much benefited by full doses of iron. Basham's 
mixture or the tincture of the chloride of iron or the dried 
sulphate are, perhaps, the best preparations to use, and their 



432 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

effect is increased by the addition of quinine. The following 
is a serviceable formula : 

& . Ferri sulph. exsiccat, gr. xxiv (to be increased to gj) 

Quininae sulph., gr. xij 

Acid, sulph urici dil., TT L x ij 

Syrupi, f^j 

Aquae menth. pip., . . . q. s. ad f ^ iij. M. 

SiG. — Two teaspoonfuls three times daily, taken diluted and after eating, for a 
child of six years. 

Diuretics can be employed at the same time, if there be no 
kidney complication, for example : 

B . Potassii acetatis, £ ij 

Spt. juniperis comp., , . f^ss 

Spt. aetheris nitrosi, . . f 3 vj 

* Syrupi, f % ij 

Aquae, q. s. ad f^vj. M. 

SiG. — Two teaspoonfuls every three hours. 

A combination of acetate of potassium, squill, and digitalis 
is often useful. 

Should this class of remedies fail, much may be accom- 
plished by a properly regulated course of purgatives. For 
this purpose, thirty grains of compound licorice powder, thirty 
grains of sulphate of magnesium, or ten grains of compound 
jalap powder, may be given from two to three times daily. 
Sometimes it is advisable to begin this treatment by two 
grains of calomel, administered at bedtime, and followed next 
morning by a teaspoonful of ruagnesia. 

It is always important to keep the skin active by a daily 
warm bath, and to maintain an equal surface temperature by 
woolen underclothing. 

The diet should contain as little fluid as possible ; thus the 
child may eat : 

For Breakfast. — A saucer of oatmeal porridge or cracked 
wheat with cream ; a soft-boiled egg ; two slices of stale bread 
or toast with butter ; a teacupful (four fluidounces) of milk. 



AFFECTIONS OF THE PERITONEUM. 433 

For Dinner. — A bit of roast chicken, or tenderloin of beef- 
steak, or roast beef or mutton ; mashed potatoes with gravy, 
or spinach or cauliflower ; two or three slices of stale bread ; 
rice pudding or junket and a glass of filtered water. 

For Supper. — A poached egg on toast, or a bowl of cream 
toast and a cup of milk. 

Between meals, some water must be taken to relieve thirst ; 
but the less, the better. 

When the fluid does not diminish after a thorough trial of 
ordinary remedies, the peritoneal cavity must be tapped. It 
is best to make the puncture with a very fine cannula ; the 
instrument having been inserted, is left in position ; a rubber 
tube is attached, and the fluid allowed to drain away slowly 
for some eight or ten hours, constant and equal pressure being 
maintained in the mean while by a broad bandage. After the 
cannula is removed, the abdomen must either be strapped or 
carefully bandaged. The effusion is never entirely removed 
in this way, but enough is taken to relieve pressure and allow 
absorption to go on. This method of operation causes so 
little pain, that, if necessary, but slight objection is offered to 
its repetition ; in very timid subjects, though, it is well to 
lessen the sensibility of the skin by the momentary applica- 
tion of ice and salt to the point selected for puncture. Para- 
centesis is often a remedial agent of much value ; though in 
some cases it is merely palliative. 



INDEX 



Abdomen in acute peritonitis, 415 
in ascites, 429 
in rachitis, 147 
in tabes mesenterica, 377 
in tuberculosis of intestines, 385 
in tuberculous peritonitis, 424 
Abnormal dentition, 206 
Abscess, in appendicitis, 332 

in perforative peritonitis, 417 
in suppurative tonsillitis, 226 
in tuberculous peritonitis, 425 
of liver. See Hepatitis, suppur- 
ative, 
peritonsillar. See Tonsillitis, sup- 
purative, 
perityphlitic. See Appendicitis, 
retropharyngeal. See Retropharyn- 
geal Abscess. 
Accidents in intussusception, 342 
Adenoid hypertrophy, 230 
dangers of, 233 
diagnosis of, 232 
etiology of, 230 
prognosis of, 233 
symptoms of, 231 
treatment of, 233 
Adenoids, 227 

Adhesions in ulcerative form of tuber- 
culous peritonitis, 422 
Air, insufflation of, in intussusception, 

355 
apparatus for, 355 
Albuminuria in amyloid liver, 399 
in ascites, 430 
in infectious follicular tonsillitis, 

217 
in lithaemia, 164 

in passive congestion of liver, 395 
in simple atrophy, 107 
in suppurative hepatitis, 410 
in tuberculous peritonitis, 424 
Amoeba coli, 312 
Amoebic dysentery. See Dysentery, 

amoebic. 
Amyloid liver. See Liver, amyloid. 



Anaemia in rachitis, 137 

massage in, 97 
Analysis of cows' and human milk, 33 
Anthelmintics, 366 et seq. 
Antiseptics in entero-colitis, 300 
Aphtha, Bednar's, 183 

treatment of, 183 
Aphthae, 178 
Aphthous stomatitis. See Stomatitis, 

aphthous, 178 
Apparatus for gavage, 89 

for lavage, 90 
Appendiceal concretions, 332 
Appendicitis, 331 
catarrhal, 331 

diagnosis from ulcerative 

form, 337 
prognosis of, 337 
chronic relapsing, 336 

treatment of, 340 
diagnosis of, 336 

from intussusception, 337 
etiology of, 332 
morbid anatomy of, 331 
prognosis of, 337 
symptoms of, 333 
treatment of, 337 

of convalescence, 340 
perforative, 331 

prognosis of, 337 
recurrent, 336 

treatment of, 340 
ulcerative, 331 
Appetite in gangrenous stomatitis, 191 
in helminthiasis, 363 
in lithaemia, 161 
in parasitic stomatitis, 199 
in rachitis, 139 
in tape worm, 365 
Articulations, changes in, in rachitis, 

146 
Artificial feeding, 29 
Ascaris lumbricoides, 357 
habitat of, 359 
history of, 358 
migration of, 365 



435 



436 



INDEX. 



Ascaris lumbricoides, ova of, 358 
symptoms of, 365 
treatment of, by chenopodium, 

369 
by santonin, 368 
by spigelia, 369 
Ascites, 428 

diagnosis of, 430 

from flatulent distention, 431 
from hydronephrosis, 431 
etiology of, 429 
prognosis of, 431 
symptoms of, 429 
treatment of, 408, 431 
in atrophic cirrhosis, 405 
in syphilitic hepatitis, 402 
in tabes mesenterica, 378 
in tuberculous peritonitis, 424 
Aspiration of abscess of liver, 41 1 
Atrophic cirrhosis, 403 
course of, 405 
diagnosis of, 406 
morbid anatomy of, 403 
symptoms of, 405 
treatment of, 407 
Atrophy, simple, 101 

diagnosis of, 107 

from acute tuberculosis, 

108 
from syphilis, 107 
from tuberculous menin- 
gitis, 108 
etiology of, 101 
morbid anatomy of, 104 
prognosis of, 108 
symptoms of, 104 
treatment of, 108 
Attenuants, 40 
Auvard's incubator, 86 



B. 

Bacillus tuberculosis in tabes mesen- 
terica, 377 
Bacteria in cholera infantum, 304 
in entero-colitis, 292 
in membranous dysentery, 313 
in noma, 192 
in peritonitis, 414 
Bacterium coli commune in appendici- 
tis, 333 
in peritonitis, 414 
Barley jelly, 44 

water, 41 
Bath, bran, 79 



Bath, cold, 78 

cooled, 78 

hot, 78 

in aphthous stomatitis, 182 

in cholera infantum, 308, 309 

in congestion of liver, 396 

in dysentery, 3 1 5 

in simple pharyngitis, 213 

medicated, 79 

mercurial, 79 

mustard, 79 

nitro- muriatic, 79 

salt, 79 

soda, 79 

temperature of, 77 

time of, 77 
Bathing, 77 

in acute intestinal catarrh, 274 

in chronic gastric catarrh, 248 
intestinal catarrh, 286 

in entero-colitis, 297 

in icterus neonatorum, 389 

in lithaemia, 17 1 

in mucous disease, 263 

in rachitis, 154 

in simple atrophy, no 

in tabes mesenterica, 382 
Bed clothes, 83 
Bednar's aphtha, 183 
Beef-broth, 45 
Beef juice, raw, 69, 284 
Beef tape- worm. See Taenia saginata. 
Biliary cirrhosis. See Hypertrophic 

cirrhosis. 
Binder, abdominal, 80 

in congestion of liver, 396 
Bones, changes in, in rachitis, 141,^/ seq. 
Bothriocephalus latus, 363 

habitat of, 363 
Bottle, care of, 7 1 

cleansing of, 71 

dangerous form of, 102 

feeding, 70 

manner of holding, 72 
Brain in rachitis, 138 
Bran-bath, 79 

Brandy-and-egg mixture, 354 
Breast of good nurse, 28 
Breast milk, analysis of, 33 



C. 

Cascitis. See Appendicitis. 
Calcareous change in mesenteric 
glands, 378 



INDEX. 



437 



Cancer of liver, 412 
Casein, 34 

Catarrh, acute gastric. See Gastric 
Catarrh, acute, 
acute intestinal. See Intestinal 

Catarrh, acute, 
chronic gastric. See Gastric Ca- 
tarrh, chronic, 
gastro-intestinal. See Gastro- 
intestinal Catarrh, chronic, 
intestinal. See Intestinal Ca- 
tarrh, chronic, 
of tonsils, 215 
Cauterization in noma, 195 
Cestodes, 356 
Chicken-broth, 45 

Children, general management of, 17 
Cholera infantum, 302 
course of, 305 
diagnosis of, 306 

from Asiatic cholera, 306 
from entero-colitis, 306 
etiology of, 303 
morbid anatomy of, 303 
prognosis of, 306 
symptoms of, 304 
treatment of, 306 
Chorea, massage in, 99 

treatment of, 99 
Chronic gastric catarrh in infants, 240 
Chronic vomiting, 240 
Cirrhosis of liver. See Liver, cirrhosis 
of. 
atrophic, diagnosis of, 406 

symptoms of, 405 
hypertrophic, diagnosis of, 406 
from acute yellow 
atrophy, 406 
symptoms of, 406 
Clothing, 80 

in acute intestinal catarrh, 274 
in chronic gastric catarrh, 247 
in chronic intestinal catarrh, 283 
in entero-colitis, 297 
in mucous disease, 263 
Clysters, 325 
Colic, 320 

cry of, 21 
etiology of, 320 
massage in, 97 
symptoms of, 321 
treatment of, 321 
Collapse in cholera infantum, 305 

in intussusception, 347 
Collapse of lung in rachitis, 138 



Colon and rectum, inflammation of. 

See Dysentery. 
Colostrum, 18 
Condensed milk, 35 

when allowable, 36 
Congenital malformation of bile ducts, 

389 
Congestion of liver, 393 

active, symptoms of, 394 
passive, symptoms of, 395 
Constipation, habitual, 323 
diagnosis of, 325 
etiology of, 324 
prognosis of, 325 
symptoms of, 324 
treatment of, 325 
in perforative peritonitis, 417 
massage in, 96 
Convulsions in chronic intestinal ca- 
tarrh, 280 
treatment of, 173 
Cough in helminthiasis, 364 

in chronic gastro-intestinal catarrh, 
267 
Counter-irritation in entero-colitis, 301 
Cows' milk, analysis of, 33 

characteristics of, 32 
tests for, 32 
Craniotabes, 135, 141 
Cranium, changes of, in rachitis, 141 
Creeping, 83 
Crib, 83 

Croupous tonsillitis, 215 
Cry of colic, 21 

of hunger, 21 
Cysticercus cellulose, 362 



D. 

Deafness in tonsillar hypertrophy, 228 
Death, cause of, in intussusception, 350 

in rachitis, 147 
Decubitus in acute peritonitis, 415 

in appendicitis, 334 

in tuberculous peritonitis, 425 
Deformities in rachitis, 134 
Deformity of chest in tonsillar hyper- 
trophy, 228 

in scorbutus, 119 
Dentition, 205 

abnormal, 206 

delayed, 207 

diseases attributed to, 208 

irregular, 207 

in rachitis, 136, 142 



438 



INDEX. 



Diarrhoea, chronic. See Intestinal Ca- 
tarrh, chronic, 
febrile. See Entero-colitis. 
from oxyures, 365 
in icterus neonatorum, 389 
in older children, 271 
in pyaemic abscess of liver, 410 
in tabes mesenterica, 379 
simple. See Intestinal Catarrh, 

acute, 
summer. See Entero-colitis. 

Diet during first week, 42 
from 2d to 6th week, 42 
from 6th week to 3d month, 42 
from 3d to 6th month, 42 
during 6th and 7th months, 42 
in 8th and 9th months, 43 
loth month to 14th month, 44 
18 months to 2^ years, 46 
in acute gastric catarrh, 239 
in acute intestinal catarrh, 272 
.in acute intestinal catarrh in chil- 
dren, 275 
in amyloid disease of liver, 400 
in aphthous stomatitis, 1 81 
in ascites, 432 
in childhood, 75 
in cholera infantum, 309 
in chorea, 99 
in chronic diarrhoea of childhood, 

. 28 5 

in chronic gastric catarrh, 245 

in chronic intestinal catarrh, 283 

in cirrhosis of liver, 408 

in colic, 322 

in congestion of liver, 396 

in diarrhoea of tabes mesenterica, 

383 
in entero-colitis, 297 
in habitual constipation, 327, 328 
in infectious tonsillitis, 218 
in intussusception, 353 
in lithaemia, 169 
in mucous disease, 261 
in parasitic stomatitis, 200 
in peritonitis, 420 
in rachitis, 151 
in simple atrophy, 109 
in simple follicular tonsillitis, 222 
in simple pharyngitis, 214 
in tabes mesenterica, 381 
in treatment of tape- worm, 370 
in tuberculous peritonitis, 427 
no-milk, 298 
Dietary for infants, table of, 43 



Diphtheria of mouth, 202 
Diphtheritic sore throat, 215 
Drink, 47 

Duodenal catarrh. See Jaundice. 
Duparcque's method for detecting as- 
cites, 415, 430 
symptoms of retropharyngeal ab- 
scess, 234 
Dysentery, 309 
amoebic, 312 

diagnosis of, 313 
morbid anatomy of, 312 
prognosis of, 313 
symptoms of, 313 
treatment of, 315 
catarrhal, 309 

diagnosis of, 311 
duration of, 31 1 
etiology of, 310 
morbid anatomy of, 310 
prognosis of, 31 1 
symptoms of, 310 
treatment of, 314 
membranous, 313 

diagnosis of, 314 
morbid anatomy of, 313 
prognosis of, 314 
symptoms of, 314 
treatment of, 315 



E. 

Eating between meals, 76 
Eczema in lithaemia, 165 
Effervescing draught, 222 
EfHeurage, 92 
Effusion in cardiac disease, 430 

in hepatic disease, 430 

in peritonitis, 430 
Electricity with massage, 98 
Emaciation in rachitis, 137 
Emphysema in rachitis, 138 
Enemata against oxyures, 367 

forced, in intussusception, 354 

laxative, 326 

purgative, in habitual constipation, 

325 

Enlargement of liver in cirrhosis, 404 
of spleen in amyloid disease, 399 
in icterus neonatorum, 390 
Entero-colitis, 289 

chronic. See Intestinal Catarrh, 

chronic, 
diagnosis of, 295 

from cholera infantum, 295 



INDEX, 



439 



Entero-colitis, etiology of, 290 
evacuations in, 293 
morbid anatomy of, 289 
prognosis of, 295 
symptoms of, 293 
treatment of, 296 

Epiphysis detached in scorbutus, 1 13 

Evacuations in acute intestinal catarrh, 
270 
in acute peritonitis, 416 
in amoebic dysentery, 313 
in ascites, 429 
in catarrhal dysentery, 31 1 
in catarrhal jaundice, 392 
in cholera infantum, 304 
in chronic diarrhoea, 281 
in chronic gastric catarrh, 243 
in chronic intestinal catarrh, 277 
in chronic peritonitis, 418 
in congestion of liver, 394 
in habitual constipation, 324 
in helminthiasis, 364 
in icterus neonatorum, 388 
in intussusception, 346, 347 
in lithaemia, 161 
in mucous disease, 258 
in proctitis, 318 
in rachitis, 139 
in tabes mesenterica, 379 
in tuberculosis of intestines, 385 
in tuberculous peritonitis, 424, 425 
in umbilical infection, 391 

Exanthemata complicating chronic 
diarrhoea, 279 

Exercise, 83 

in mucous disease, 264 
insufficient, in lithaemia, 160 

Extremities, changes in bones of, 143, 
145 

F. 

Faecal fistula after perforative peri- 
tonitis, 417 
Farinaceous foods, 36 
Fatty liver. See Liver, fatty. 
Febrile diarrhoea. See Entero-colitis. 
Feeding, 18 

artificial, 29 

before breast secretion, 19 

by wet-nurse, 27 

from maternal breast, 18 

in gradual weaning, 23 

mixed, 22 

table of intervals of, 39 

theoretical basis for, 62 



Fever in enteio-colitis, 294 
Fissure of nipple, 25 

treatment of, 26 
Fissures in syphilitic stomatitis, 203 
Flours, baked, 44 
Fluctuation in ascites, 429 
Follicular tonsillitis, 215 
Fontanel le in chronic intestinal catarrh, 

in entero-colitis, 294 

in rachitis, 141 
Food, daily quantity of, 37 

insufficient, 101 

Meigs', 49 
Foods, infants', 37 
Foreign bodies in appendicitis, ^^ 
Fractures in scorbutus, 1 19 
Friction, 93 



Gangrene in intussusception, 349 

of intussusceptum, 343 
Gangrenous stomatitis. See Stomatitis, 

gangrenous. 
Gastric catarrh, acute, 237 

diagnosis of, 238 
lesion in, 237 
prognosis of, 238 
symptoms of, 237 
treatment of, 238 
Gastric catarrh, chronic, 240 

diagnosis of, 244 
etiology of, 241 
farinaceous foods caus- 
ing, 241 
morbid anatomy of, 240 
prognosis of, 245 
symptoms of, 242 
treatment of, 245 
Gastric ulcer. See Stomach, ulcer 

of. 
Gastro-intestinal catarrh, chronic, 252. 
See also Mucous Dis- 
ease, 
from worms, treatment 

of, 375 
massage in, 95 
Gastro-malacia, 252 
Gavage, 89 

de r en fort, 90 
Gelatin, 41 

Genitalia, noma of, 193 
Gruels, dextrinized, 70 
Gum lancing, 209 
Gums in scorbutus, 1 15, 117 



44<3 



INDEX. 



H. 

Habitual constipation. See Constipa- 
tion, habitual. 
Haematemesis, 249 
spurious, 250 

diagnosis of, 251 
Harrison's groove, 143 
Hatching cradle. See Incubator. 
Hemorrhage in hypertrophic cirrhosis, 
406 
in icterus neonatorum, 390 
in intussusception, 349 
in membranous stomatitis, 203 
in scorbutus, 118 
in syphilitic hepatitis, 402 
from umbilicus in icterus, 390 
Hemorrhoids in atrophic cirrhosis, 405 
Hepatic circulation, changes at birth 

in, 388 
Hepatitis, suppurative, 408 
diagnosis of, 410 

from empyema, 411 
from malaria, 410 
lesion in, 408 
prognosis of, 41 1 
symptoms of, 408 
treatment of, 411 
Hepatitis, syphilitic. See Liver, syph- 
ilitic inflammation of. 
Herd of cows, care of, 73 
Hob-nailed liver, 403 
Holt's rules for altering percentages, 62 
Home modification of milk, 65 

Westcott's method, 66 
Human milk, analysis of, 31 

proteids of, 32 
Humanized milk, 52 

analysis of, 5 2 
Hunger, cry of, 21 
Hydatid disease of liver, 412 
Hydrocephalus, spurious, 107 
Hygiene of acute intestinal catarrh, 274 
of chronic gastric catarrh, 248 
of chronic intestinal catarrh, 282 
of sleeping room, 82 
Hyperesthesia in scorbutus, 1 15 
Hypertrophic cirrhosis, diagnosis of, 406 
morbid anatomy of, 404 
symptoms of, 406 
Hypertrophy of tonsils, 227 

I. 

Icterus. See Jaundice, 
in older children, 392 



Icterus neonatorum, 388 
grave type, 388 

etiology of, 389 
prognosis of, 390 
symptoms of, 390 
treatment of, 391 
mild type, 388 

etiology of, 388 
jaundice in, 388 
treatment of, 389 
Ileo-colitis. See Dysentery. 
Immobility in scorbutus, 116 
Incisions in gum lancing, 210 
Incubator, Tarnier's, 85 

Paris statistics of, 88 
Indigestion, habitual, 253 
diagnosis of, 257 
etiology of, 253 
prognosis of, 257 
symptoms of, 255 
treatment of, 261 
Infantile paralysis, massage in, 97 

scurvy. See Scorbutus. 
Infants' foods, 37 
Infants, management of weak, 84 

premature, 84 
Intestinal catarrh, acute, 268 

diagnosis of, 271 

from enterocolitis, 

271 
from tuberculous 
diarrhoea, 271 
etiology of, 269 
hygiene in, 274 
pathology of, 268 
prognosis of, 270 
symptoms of, 270 
treatment of, 272 
Intestinal catarrh, chronic, 276 

complications of, 278 
diagnosis of, 281 

from intestinal tu- 
berculosis, 281 
hygiene in, 282 
in childhood, 280 
morbid anatomy of, 276 
prognosis of, 282 
symptoms of, 277 
treatment of, 282 
Intestinal irrigation in cholera infan- 
tum, 307 
worms. See Worms, intestinal. 
Intestines, tuberculosis of, 383 
etiology of, 384 
symptoms of,. 384 



INDEX. 



441 



348 



Intestines, tuberculosis of, treatment 

of, 385 
Intubation in retropharyngeal abscess, 

235 
Intussusception, 340 

accidents of spontaneous cure, 343 

after death, 341 

agonal, 341 

chronic, 350 

treatment of, 356 

diagnosis of, 350 
from colic, 351 
from dysentery, 351 
from faecal accumulation, 351 
fromperforativeperitonitis, 35 1 

etiology of, 345 

extent of, 342 

ileo-aecal in infants, 344 

in childhood, evacuations 
hemorrhage in, 349 
symptoms of, 348 

mechanical reduction of, 354 

mechanism of, 342 

morbid anatomy of, 342 

multiple, 341 

prognosis of, 352 

results of, 343 

symptoms of, 346 

in childhood, 348 
in infancy, 346 

treatment of, 352 

with slight constriction, 344 

with symptoms, 342 

without symptoms, 341 
Intussusceptum, 342 
Intussuscipiens, 342 
Invagination. See Intussusception. 
Inward spasms, 106 
Irrigation of colon in dysentery, 315 



J- 

Jaundice, 387 

after birth, 387 
catarrhal, 392 

etiology of, 392 

symptoms of, 392 

treatment of, 392 
in abscess of liver, 409, 410 
in icterus neonatorum, 390 
in mild type of icterus neonatorum, 

388 
in older children, 392 
in syphilitic hepatitis, 402 

37 



K. 

Klebs-Loeffler bacillus in membranous 
stomatitis, 203 



Laboratory milk, 60 

advantages of, 60 
disadvantages of, 63 
for premature infants, 88 

Lactalbumin, 34 

Lactometer, t,^ 

Lancing of gums, 209 

Laparotomy in intussusception, 354 

Lavage of stomach, 90 

indications for, 91 

in cholera infantum, 307 

Laxative confection, 331 
enemata, 326 

pjn, 330, 33^ 

Laxatives in habitual constipation, 329 

Lesions of tuberculosis of intestines, 383 

Leucocytosis in appendicitis, 336 

Liebig's foods, 44 

Lienteric diarrhoea, treatment of, 288 

Ligaments in rachitis, 136 

Lime, saccharated solution of, 40, 339 

Lime water, 39 

recipe for, 40 
Lithaemia, 159 

diagnosis of, 166 
etiology of, 160 
gastro-intestinal, 163 
prognosis of, 168 
symptoms of, 160 
treatment of, 168 
Liver, abscess of. See Hepatitis, sup- 
purative, 
affections of, 387 
amyloid disease of, 398 
course of, 399 
diagnosis of, 400 

from congestion, 400 
from fatty infiltration 
of, 400 
etiology of, 398 
morbid anatomy of, 398 
prognosis of, 400 
symptoms of, 399 
treatment of, 400 
cancer of, 412 
cirrhosis of, 403 

diagnosis of, 406 
etiology of, 404 



442 



INDEX. 



Liver, cirrhosis of, morbid anatomy of, 
403 
prognosis of, 407 
symptoms of, 405, 406 
treatment of, 407 
congestion of, 393 

diagnosis of, 395 
etiology of, 394 
morbid anatomy of, 393 
prognosis of, 395 
symptoms of, 394 
treatment of, 395 
enlargement of, diagnosis of, 395 
in icterus neonatorum, 390 
in amyloid disease, 399 
fatty, 396 

diagnosis of, 396 
etiology of, 397 
morbid anatomy of, 396 
prognosis of, 397 
symptoms of, 396 
treatment of, 398 
hydatid disease of, 412 
in catarrhal jaundice, 392 
in rachitis, 137, 147 
in syphilitic hepatitis, 402 
pus, 410 

syphilitic inflammation of, 401 
diagnosis of, 402 
morbid anatomy of, 401 
prognosis of, 402 
symptoms of, 402 
treatment of, 402 
tuberculosis of, 412 
Lumbricoid worms. See Ascaris lum- 

bricoides. 
Lymph glands in acute infectious ton- 
sillitis, 2 [6 
in aphthous stomatitis, 179 
in habitual indigestion, 255 
in helminthiasis, 363 
in rachitis, 138, 147 
in simple pharyngitis, 212 
in ulcerative stomatitis, 185 
Lymphatism, 227 

M. 

Malformation of bile duct, congenital, 

389 
Management of children, 17 
Marasmus, IOI 
Massage, 92 

a frictions, 93 

benefits of, 94 



Massage in anaemia, 97 
in chorea, 99 
in chronic gastro-intestinal catarrh, 

95 
in colic, 97 
in constipation, 97 
in infantile palsy, 97 
Meal, duration of, 72 
Measly meat, 361 
Meigs' food, 49 
Melsena, 250 
Membranous stomatitis. See Stomatitis, 

membranous. 
Mercurial bath, 79 

Mesenteric glands, tuberculosis of, 376 
in tuberculosis of intestines, 

384 
Meso-colon, conformation of, in in- 
fancy, 345 
Migraine, 165 

treatment of, 173 
Milk, analysis of human, 31 
boiled, 48 
care of, 73 

characteristics of human, 28 
characteristics of cows', 32 
condensed, 35, 48 
contamination of, 242 
home modification of, 65 
humanized, 5 2 
laboratory, 60 
modification of cows', 39 
modified, 59 
percentage, 60 
predigested, 50 
substitutes for, 69 
tests for cows', 32 
human and cows' compared, 33 
human, substitute for, 32 
Milk-infection, acute. See Cholera In- 
fantum. 
Mixed feeding, 22 
Modified milk, 59 
Mouth, affections of, 175 
Mouth-breathing in tonsillar hypertro- 
phy, 228 
Mucous disease, 257 

after pertussis, 257 
course of, 260 
diagnosis of, 260 

from tuberculosis, 260 
etiology of, 257 
prognosis of, 261 
symptoms of, 258 
treatment of, 261 



INDEX. 



443 



Mucous patches in syphilitic stomatitis, 
204 

Multiple abscess of liver, 408 
prognosis of, 411 
symptoms of, 410 

Mustard bath, 79 

Mutton-broth, 45 

N. 

Necrosis of jaw in noma, 191 

in ulcerative stomatitis, 186 
treatment of, 189 
Nematodes, 356 
Nightdress, 80 
Nipple, fissure of, 25 
Noma. See Stomatitis, gangrenous. 
Noma of genitalia, 193 
Nursing, constant, impropriety of, 20 
interval of, in first six weeks, 20 
after six weeks, 2 1 
after six months, 22 
manner of, 19 
regularity in, 20 
Nutmeg liver, 393 



Oatmeal as a laxative, 327 

gruel, 323 
Obstruction, intestinal, in infancy, 341 
GEdema in atrophic cirrhosis, 405 

in passive congestion of liver, 395 
in tuberculous peritonitis, 424 
of legs in tabes mesenterica, 378 
Oleum phosphoratum, 156 
Outing, 83 

Oxyuris vermicularis, 357 
habitat of, 357 
history of, 357 
ova of, 357 
symptoms of, 364 
treatment of, 366 
by quassia, 367 

P. 

Pain in abscess of liver, 409 
in acute peritonitis, 415 
in appendicitis, 334 
in ascites, 429 
in atrophic cirrhosis, 405 
in chronic peritonitis, 418 
in congestion of liver, 394 
in helminthiasis, 364 
in intussusception, 346 



Pain in perforative peritonitis, 417 
in tabes mesenterica, 379 
in tuberculous peritonitis, 423 
Papules in syphilitic stomatitis, 204 
Paracentesis abdominis for ascites, 433 
Parasites, intestinal, 356 
Pasteurization, 56 
Pasteurizer, Freeman's, 58 
Pelvis, changes in rachitic, 144 
Peptogenic milk powder, 47, 51 
Peptonization, 49 

partial, after enterocolitis, 299 
in diet of chronic intestinal 
catarrh, 284 
Percentage milk, 60 
Perforating ulcer of stomach, 250 
Perforation of bowel in tuberculous 
peritonitis, 422 
of cheek in noma, 191 
in appendicitis, 332 
in tuberculous peritonitis, 425 
Peritoneum, affections of, 413 
Peritonitis, 413 

diagnosis of, 418 
etiology of, 414 
morbid anatomy of, 413 
symptoms of, 414 
surgical treatment of, 421 
treatment of, 419 

acute local, morbid anatomy 0^413 
general, diagnosis of, 418 
from colic, 418 
from rheumatism of 
abdominal mus- 
cles, 418 
morbid anatomy of, 413 
primary, prognosis of, 419 

symptoms of, 415 
tuberculous, 426 

diagnosis of, 426 

from typhoid fever, 
427 
chronic, 414 

general, morbid anatomy of, 

414 
local, 414 
fcetal, 414 

general in appendicitis, 335 
in intussusception, 343 
latent, diagnosis of, 418 
localized plastic, 334 
suppurative, 334 
perforative, 414 

prognosis of, 419 
symptoms of, 417 



444 



INDEX. 



Peritonitis, primary, 414 

septic, symptoms of, 417 
tuberculous, 421 

ascitic form of, 422 

prognosis of, 427 
complications of, 425 
course of, 425 
diagnosis of, 426 

from chronic intestinal 
catarrh, 426 
etiology of, 423 
fibrous form of, 422 

prognosis of, 427 
morbid anatomy of, 421 
prognosis of, 427 
symptoms of, 423 
treatment of, 427 
ulcerative form of, 422 

prognosis of, 427 
with empyema, 419 
Peritonsillar abscess. See Tonsillitis, 

suppurative. 
Perityphlitic abscess. See Appendicitis. 
Perityphlitis. See Appendicitis. 
Permanent teeth, 207 
Pertussis a cause of mucous disease, 

257 
Petrissage, 92 
Pharyngeal tonsil, 230 
Pharyngitis, simple, 211 

diagnosis of, 213 

from croupous pneumo- 
nia, 213 
from digestive disorder, 

213 
from diphtheria, 213 
from scarlatina, 213 
duration of, 213 
etiology of, 211 
lesion in, 211 
symptoms of, 211 
treatment of, 213 
Pigeon-breast, 232 
Pills, laxative, 338 
Pneumococcus in peritonitis, 414 
Pneumonia, hypostatic, in chronic in- 
testinal catarrh, 279 
Pork tape-worm. See Taenia solium. 
Predigestion, 49 

partial, 49 
Prerachitic stage, 139 
Prescription writing for laboratory mix- 
tures, 61 
Proctitis, 317 

catarrhal, 317 



Proctitis, catarrhal, diagnosis of, 318 
from catarrhal diarrhoea, 

318 
etiology of, 317 
prognosis of, 319 
symptoms of, 317 
treatment of, 319 

Prolapsus ani from oxyures, 365 

Prophylaxis of tabes mesenterica, 381 

Proteids of human milk, 32 

Pruritus ani from oxyures, 364 

Pseudo-diphtheria, 215 

Pulse in acute gastric catarrh, 238 
in acute peritonitis, 415 
in appendicitis, 334 
in catarrhal dysentery, 310 
in catarrhal jaundice, 392 
in cholera infantum, 305 
in chronic gastric catarrh, 243 
in entero-colitis, 294 
in gangrenous stomatitis, 190 
in habitual indigestion, 255 
in helminthiasis, 364 
in hypertrophic cirrhosis, 406 
in lithaemic attack, 163 
in mucous disease, 260 
in parasitic stomatitis, 199 
in peritonitis, 415 
in septic peritonitis, 418 
in simple pharyngitis, 211 
in suppurative tonsillitis, 224 
in tuberculous peritonitis, 424, 425 
in ulcerative stomatitis, 186 
in umbilical infection, 391 

Pus of liver abscess, 410 

Pyaemic abscess of liver, 410 

Q- 

Quinsy. See Tonsillitis, suppurative. 



Rachitic rosary, 142 
Rachitis, 130 

bone changes in, 135 
deformities in, 134 

complications of, 150 

diagnosis of, 148 

from hydrocephalus, 149 
from paralysis, 149 
from scurvy, 149 

diet in, 151 

etiology of, 130 

food factors in, 131 

hygiene in, 152 

prognosis of, 150 



INDEX. 



445 



Rachitis, morbid anatomy of, 132 
stages of, 132 
symptoms of, 139 
treatment of, 151 

of complications, 157 
Rash in lithaemia, diagnosis of, from 
measles, 166 
from rubella, 167 
from scarlet fever, 167 
Raw-beef juice, 69, 284 
Regimen in tabes mesenterica, 381 
Retropharyngeal abscess, 233 
diagnosis of, 235 

from croup, 235 
from cedema of glottis, 
235 
etiology of, 233 
pathology of, 234 
prognosis of, 235 
symptoms of, 234 
treatment of, 235 
Ribs, changes in, in rachitis, 142 
Rice water, 273 
Rickets. See Rachitis. 

acute, 120 
Rosary, rachitic, 142 
Roseolous rash in lithaemia, 165 
Rubbing, 95 



Saccharated solution of lime, 339 
Saccharomyces albicans, 196 
Salt bath, 79 

Sausage-shaped tumor in intussuscep- 
tion, 350 
Scolex of taenia saginata, 361 

of taenia solium, 362 
Scorbutus, in 

and rickets, 120 

diagnosis of, 1 19 

diet for, 128 

etiology of, ill 

faulty foods causing, 112 

pathological anatomy of, 1 13 

prognosis of, 121 

symptoms of, 1 14 

table of author's cases of, 122-127 

treatment of, 128 
Scurvy. See Scorbutus. 
Seashore treatment of entero-colitis, 296 
Separation of intussusception, treatment 

of, 35 6 
Serous effusion in chronic intestinal 
catarrh, 279 



Sheath of intussusception, 342 

Shoes, 81 

Sinus thrombosis in chronic intestinal 

catarrh, 280 
Skin in lithaemia, 165 
Sleep, 81 

disturbed, in lithaemia, 161 
rules for, 81 
Sleeping room, hygiene of, 82 
Slough, separation of, in intussuscep- 
tion, 349 
Soda bath, 79 

Softening of glands in tabes mesenter- 
ica, 378 
Softening of stomach, 252 
Spleen, enlarged, in amyloid liver, 399 
in cirrhosis of liver, 404 
in icterus neonatorum, 390 
in rachitis, 137, 147 
in syphilitic hepatitis, 402 
palpation of, 405 
Staphylococci in infectious tonsillitis, 

216 
Starch as an attenuant, 41 
Stercoraceous vomiting in intussuscep- 
tion, 348 
Brinton's theory of, 348 
Sterilization, 53 
at 167 , 56 
at 212 , 53 
Sterilized milk, characters of, 55 

digestibility of, 56 
Sterilizer, author's, 53 
Stomach and intestines, affections of, 

237 
capacity of, 38 
cough, 267 
lavage of, 90 
softening of, 252 
ulcer of, 249 

diagnosis of, 250 

from gastric hemorrhage, 
250 
treatment of, 250 
Stomatitis, aphthous, 178 

confluent form of, 180 
diagnosis of, 180 

from thrush, 180 
from ulcerative stomati- 
tis, 180 
diet in, 181 
duration of, 179 
etiology of, 178 
lesion of, 178 
symptoms of, 178 



446 



INDEX. 



Stomatitis, aphthous, treatment of, 
1 80 
catarrhal, 175 

etiology of, 175 
symptoms of, 176 
treatment of, 177 
gangrenous, 189 

diagnosis of, 193 

from malignant pustule, 
194 
diagnosis of, from ulcerative 

form, 193 
etiology of, 189 
mortality of, 194 
pathology of, 192 
prognosis of, 194 
symptoms of, 189 
treatment of, 194 
membranous, 202 

diagnosis of, 203 
lesions of, 202 
symptoms, 202 
treatment of, 203 
parasitic, 195 

diagnosis of, 199 

from aphthous form, 199 
etiology of, 196 
lesions of, 196 
prognosis of, 200 
symptoms of, 197 
treatment of, 200 
syphilitic, 203 

initial lesion in, 203 
treatment of, 205 
ulcerative, 183 

course of, 186 ■ 
diagnosis of, 186 
diet in, 187 
etiology of, 184 
lesions of, 183 
prognosis of, 187 
symptoms of, 184 
treatment of, 187 
Stools. See Evacuations. 
Streptococci in infectious tonsillitis, 216 

in peritonitis, 414 
Strippings, 48 

Summer diarrhoea. See Entero-colitis. 
Suppositories in habitual constipation, 

326 
Suppurative hepatitis. See Hepatitis, 
suppurative, 
tonsillitis. See Tonsillitis, suppu- 
rative. 
Sweating in rachitis, 139 



Syphilis of liver. See Liver, syphili- 
tic inflammation of. 
Syphilitic hepatitis. See Liver, syphi- 
litic inflammation of. 
stomatitis. See Stomatitis, syphi- 
litic. . 



Tabes mesenterica, 376 

etiology of, 377 
Tabes mesenterica, diagnosis of, 379 
from faecal accumulation, 

380 
from intestinal catarrh, 

379 
hygiene of, 381 
prognosis of, 380 
symptoms of, 377 
treatment of, 381 
Table of dietary, 43 
Taenia cucumerina, 362 
nana, 363 
saginata, 360 

habitat of, 360 
ova of, 360 
solium, 361 
Taeniae, 359 

search for head of, 374 
preparatory treatment of, 370 
symptoms of, 365 
treatment of, by kameela, ^t, 
by koosso, 374 
by male fern, 372 
by pelletierine, 371 
by pomegranate, 371 
by pumpkin seed, 374 
by turpentine, 373 
Tape-worm, frequency of, in America, 

362 
Tapotement, 93 
Tarnier's incubator, 85 
Taxis in intussusception, 354 
Teeth, Hutchinson's, 204 

in hereditary syphilis, 204 
permanent, 207 

eruption of, 207 
premature, 206 
temporary, 205 

eruption of, 205 
symptoms due to, 206 
Temperature in acute peritonitis, 415 
in appendicitis, 334 
in intussusception, 347 
in lithaemic attack, 163 
in tuberculous peritonitis, 424 



INDEX. 



447 



Tenderness in congestion of liver, 

394 
in rachitis, 140 

Tenesmus in amoebic dysentery, 313 
in catarrhal dysentery, 31 1 
in intussusception, 347 
in membranous dysentery, 314 

Third tonsil, 230 

Thompson's mixture, 156 

Thorax in rachitis, 139 

Thread worms. See Oxyuris vermicu- 
laris. 

Throat, affections of, 211 

Thrush. See Stomatitis, parasitic, 
secondary, symptoms of, 198 

Tongue in acute gastric catarrh, 238 
in acute intestinal catarrh, 271 
in acute peritonitis, 416 
in aphthous stomatitis, 179 
in appendicitis, 334 
in atrophic cirrhosis, 405 
in catarrhal dysentery, 311 
in catarrhal jaundice, 392 
in catarrhal stomatitis, 176 
in cholera infantum, 305 
in chronic diarrhoea of childhood, 

281 
in chronic gastric catarrh, 242, 243 
in chronic intestinal catarrh, 278, 

2 79 
in congestion of liver, 394 
in entero-colitis, 294 
in habitual constipation, 324 
in habitual indigestion, 255 
in helminthiasis, 363 
in hypertrophic cirrhosis, 406 
in intussusception, 346, 347 
in lithaemia, 161 
in mucous disease, 258 
in perforative peritonitis, 417 
in pyaemic abscess of liver, 410 
in simple pharyngitis, 212 
in tuberculous peritonitis, 423, 425 
in umbilical infection, 391 
Tonsil, third, 230 
Tonsillitis, acute infectious, 215 
diagnosis of, 217 

from diphtheria, 217 
etiology of, 216 
prognosis of, 218 
symptoms of, 216 
treatment of, 218 
follicular, 215 
simple follicular, 219 

diagnosis of, 221 



Tonsillitis, simple follicular, etiology 
of, 220 
prognosis of, 221 
symptoms of, 220 
treatment of, 221 
suppurative, 223 

diagnosis of, 225 
etiology of, 223 
morbid anatomy of, 223 
symptoms of, 224 
treatment of, 225 
Tonsils, catarrh of, 215 
excision of, 230 
hypertrophy of, 227 
etiology of, 227 
symptoms of, 227 
treatment of, 229 
Tracheotomy in retropharyngeal ab- 
scess, 236 
Traumatic abscess of liver, 408 
symptoms of, 408 
Tricocephalus dispar, 359 
habitat of, 359 
ova of, 359 
treatment of, 370 
Tropical dysentery. See Dysentery, 

amoebic. 
Tubercles in liver, 412 
Tuberculosis of intestines. See Intes- 
tines, tuberculosis of. 
of liver, 412 
of mesenteric glands. See Tabes 

mesenterica. 
miliary, with ascites, 422 

morbid anatomy of, 421 
Tuberculous deposits in peritonitis, 422 
Tuberculous peritonitis. See Periton- 
itis, tuberculous. 
Tumor in abscess of liver. 409 
in intussusception, 344, 347 
in tabes mesenterica, 378 
Typhlitis. See Appendicitis, 
stercoralis, 335 

symptoms of, 336 
treatment of, 340 
Tyrotoxicon, 74 



U. 

Ulcer of intestine in amoebic dysentery, 
312 
of stomach, 249 
Ulceration and perforation in intussus- 
ception, 343 



448 



INDEX. 



Ulceration of intestine in tabes mesen- 
terica, 379 

Ulcers in syphilitic stomatitis, 204 
in tuberculosis of intestines, 384 

Umbilical arteritis, 391 
hemorrhage, 390 
in icterus, 390 
treatment of, 391 
infection, 391 

etiology of, 391 
symptoms of, 391 
phlebitis, 391 

Uric acid infarctions, 163 
in lithaemia, 159 
in newborn, 162 

Urine in acute peritonitis, 416 
in amyloid liver, 399 
in ascites, 430 
in atrophic cirrhosis, 405 
in catarrhal dysentery, 311 
in cholera infantum, 305 
in chronic intestinal catarrh, 278 
in congestion of liver, 394 
in entero-colitis, 294 
in habitual indigestion, 256 
in helminthiasis, 364 
in hypertrophic cirrhosis, 406 
in icterus neonatorum, 389 
in intussusception, 347 
in jaundice, 387, 392 
in lithaemia, 162 
in lithaemic attack, 164 
in mucous disease, 260 
in pygemic abscess of liver, 410 
in rachitis, 139 
in scorbutus, 1 14, 118 
in simple atrophy, 107 
in tuberculous peritonitis, 424 
in umbilical infection, 391 

Urticaria in lithaemia, 165 



V. 

Veal-broth, 69 

Vertebrae, changes in, in rachitis, 143 

Vomiting, chronic, 240 



Vomiting in abscess of liver, 410 
in acute peritonitis, 415 
in appendicitis, 334 
in cholera infantum, 304 
in entero-colitis, treatment of, 298 
in intussusception, 346, 348 

Vomiting in lithasmia, 163 

in tuberculous peritonitis, 423 
stercoraceous, in appendicitis, 335 

W. 

Walking, 83 

Wasting from insufficient food, 105 
from unsuitable food, 105 
in breast-fed, 104 
in chronic intestinal catarrh, 278 
Weaning, date of, 22 
gradual, 22 
premature, 24 

indications for, in mother, 24 
in child, 26 
sudden, 23 

indications for, 24 
Westcott's method for home modifica- 
tion, 66 
Wet-nurse, feeding by, 27 
rules for selecting, 28 
Wheat water, 327 
Whey, 69 
Whip- worm. See Tricocephalus dis- 

par. 
Worms, intestinal, 356 

general symptoms of, 363 
diagnosis of, 365 
prognosis of, 366 
special symptoms of, 364 
treatment of, 366 



X. 

Xanthopsia after santonin, 369 

Y. 

Yellow-seeing after santonin, 369 



Sept 28 &qi 



SEP 11 1901 



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LIBRARY OF CONGRESS * 



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